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COXTPvIBUTIOXS 


ORTHOPAEDIC  SURGERY. 


BY 

A.  SYDNEY  ROBERTS,  M.D., 

LATE  SURGEON  TO  THE  PHILADELPHIA  HOSPITAL,  ORTHOPEDIC  SURGEON  TO  THE  OUT-PATIENT 

DEPARTMENT  IN  THE    UNIVERSITY  HOSPITAL  ;    INSTRUCTOR    IN    ORTHOPEDIC    SURGERY 

IN  THE  UNIVERSITY  OF  PENNSYLVANIA  ;  OUT-PATIENT  SURGEON  TO  THE  EPISCOPAL 

HOSPITAL;    FELLOW    OF  THE    COLLEGE    OF    PHYSICIANS    OF    PHILADELPHIA 

AND  OF  THE  AMERICAN  ORTHOP.EDIC  ASSOCIATION  |  MEMBER  OF  THE 

PENNSYLVANIA     STATE     MEDICAL     SOCIETY,     PHILADELPHIA 

COUNTY    MEDICAL   SOCIETY,  PATHOLOGICAL    SOCIETY, 

NEUROLOGICAL  SOCIETY,  ETC. 


WITH  A  BRIEF  BIOGRAPHICAL  SKETCH 


BY 


JAMES  K.  YOUNG,  M.D., 


PROFESSOR  OF    ORTHOPEDIC    SURGERY,    PHILADELPHIA  POLYCLINIC  ;    CLINICAL    PROFESSOR  OF 
ORTHOPEDIC  SURGERY,  WOMAN'S    MEDICAL   COLLEGE    OF  PENNSYLVANIA  |    INSTRUCTOR 
IN  ORTHOPEDIC  SURGERY,  UNIVERSITY  OF  PENNSYLVANIA  ;  ASSISTANT  ORTHO- 
PEDIC SURGEON,    HOSPITAL    OF    THE    UNIVERSITY    OF    PENNSYLVANIA ; 
SURGEON  TO  THE  HOSPITAL  FOR  CRIPPLED  CHILDREN. 


PHILADELPHIA 

1898. 


■n 


DORNAN,   PRINTER, 
PHILADELPHIA. 


PREFACE 


This  work  represents  all  the  collected  writings  of  the 
late  Dr.  A.  Sydney  Roberts  except  a  collection  of  quota- 
tions entitled  "In  and  Out  of  Book  and  Journal,"  which 
enjoyed  a  large  sale  as  a  popular  gift-book. 

The  present  collection  is  undertaken  for  private  distribu- 
tion only,  for  the  sole  purpose  of  increasing  the  interest 
in  the  subjects  of  which  it  treats,  and  is  prepared  by  the 
editor  as  a  debt  of  gratitude  for  many  past  kindnesses. 

Permission  has  been  generously  given  by  Messrs.  Lea 
Brothers  &  Co.,  the  J.  B.  Lippincott  Co.,  and  Messrs. 
Wm.  Wood  &  Co. 

J.  K.  Y. 


CONTENTS. 


Biographical  Sketch  of  Dr.  A.  Sydney  Roberts.     By  James  K. 

Young,  M.D. 1 

Club-foot:  Talipes.  Roberts  and  Ketch.  Reprint  from  the 
Reference  Hand-book  of  the  Medical  Sciences,  by  courtesy 
of  the  publishers,  Messrs.  Wm,  Wood  &  Co ,  who  have 
also  loaned  the  illustrations 23 

Pott's  Disease.     Keating's  Cyclopaedia?,  Vol.  III.        .         .         .     123 

The  Spinal  Arthropathies.     Medical  News,  February  14,  1885.     177 

Clinical  Lectures  on  Orthopaedic  Surgery  :  Club-foot.     Medical 

News,  March  13  and  20, 1886        .         .        .         .        .         .195 

Clinical  Lectures  on  Orthopsedic  Surgery :  Knock-knee  and 
Bow-legs,  with  Remarks  upon  Rhachitis.  Medical  News, 
February  4  and  18,  1888 237 

Flat-foot :  A  New  Plantar  Spring  for  its  Relief.     Medical  and 

Surgical  Reporter,  April  6,  1889 265 

Chronic  Articular  Osteitis  of  the  Knee-joint,  and  Description 
of  a  New  Mechanical  Splint.  Medical  News,  July  26, 
1884 283 

Deformity  of  the  Forearm  and  Hands.     Annals  of  Surgery, 

February,  1886 291 


M  E  M  0  I R 


OF 


DR.  ALGERNON"  SYDNEY  ROBERTS. 


INTRODUCTION. 


Each  profession  has  its  own  manner  of  honoring 
its  dead. 

There  is  a  custom  among  the  members  of  the 
Bar  suggestive  of  brotherhood.  When  one  dies 
who  has  adorned  the  profession,  a  general  meeting 
of  the  Bar  is  called,  a  Judge  presiding.  At  such 
meeting  each  and  every  member  may  pay  his  tribute 
to  the  departed — placing,  as  it  were,  a  flower  upon 
the  bier  of  a  brother  whose  victory  they  had  wit- 
nessed. 

In  our  profession,  that  of  medicine,  no  such  cus- 
tom obtains.  Would  it  not  be  well  by  this  or  some 
means  to  inculcate  such  a  spirit  of  camaraderie  f 

In  lieu  of  such  a  custom,  it  seems  highly  fitting 
that  I,  as  pupil,  friend,  successor,  upon  whom  in 
some  measure  his  mantle  has  fallen,  should  pay  my 
tribute  to  the  sacred  memory  of  the  departed.  When 
one  of  the  medical  profession  whose  ability  and 
attainments  mark  his  individuality  pre-eminent 
passes  into  eternity,  those  who  linger  may  take 
note  of  his  scholarly  attainments  and  professional 
skill,  and  emulate  his  many  virtues. 

Biographies  of  men  of  eminence  and  merit,  while 
calculated  to  please  a  large  class  of  readers,  have  a 


4  MEMOIR  OF  A.  S.  ROBERTS. 

greater  and  more  intrinsic  value.  They  present  to 
those  in  the  heyday  of  youth  a  stimulus  and  encour- 
agement ;  to  those  in  the  meridian  of  their  career, 
the  satisfaction  that  a  justifying  parallel  may  be 
discovered;  while  to  those  who  are  entering  the 
evening  of  well-earned  rest  from  labor,  a  reconcilia- 
tion may  often  be  found  by  adopting,  as  Cooper 
remarks,  "the  comfortable  self-assurance  that  the 
frowns  of  fortune  or  some  unlooked-for  fatality 
have  alone  prevented  them  from  enjoying  a  similar 
distinction  or  becoming  equally  useful  members  of 
society." 

If  in  the  present  undertaking  my  expressions 
occasionally  savor  somewhat  of  enthusiasm,  my  re- 
spect for  him  when  a  student,  my  gratitude  to  him 
as  his  pupil,  and  the  affection  borne  him  during  my 
later  association  with  him,  may  be  offered  in  apology 
of  its  degree  if  not  in  justification  of  its  fault. 

I  would  take  this  opportunity  of  expressing  my 
deep  sense  of  gratitude  to  those  friends  who  have 
furnished  me  with  various  data  relating  to  the  sub- 
ject  of  this  history,  without  which  it  would  have 
been  incomplete. 

Dr.  Roberts  was  the  son  of  Algernon  S.,  Jr.,  and 
Sarah  (Carstairs)  Roberts,  grandson  of  Algernon 
S.  Roberts.  He  combined  the  sturdy  elements  of 
the  Welsh  blood  with  the  purest  Scotch,  his  father's 
Welsh  ancestry  having  first  settled  in  this  country 
in  1683,  and  his  mother  coming  of  a  long  line  of 
Scotch  ancestors. 

He  was  born  December  19, 1855,  in  Philadelphia. 
His  early  education  was  received  at  Ilallowell  pri- 


INTB  OD  UCTION.  5 

vate  school,  from  private  tutors,  and  especially  from 
Mr.  Henry  Galbraith  Ward,  now  a  distinguished 
lawyer  in  New  York  city.  His  education  and  prep- 
aration for  college  were  completed  at  an  early  age, 
as  a  private  pupil  of  Professor  Thomas  Chase,  of 
Haverford  College.  The  influence  of  Professor 
Chase  and  Mr.  Ward  upon  the  development  of  his 
mind  is  shown  in  the  scope  of  his  medical  works 
and  the  character  of  the  literature  produced  by  him. 

When  Mr.  Ward  first  met  him  he  was  a  slight 
and  rather  shy  boy,  but  constantly  improving  in 
strength  and  confidence.  His  remembrance  of  Dr. 
Roberts  is  as  a  very  favorite  pupil.  He  was  very 
regular  and  faithful  in  his  studies,  and  gave  promise 
of  a  future  which  he  afterward  developed  in  his 
chosen  profession.  He  was  restive  under  restraint, 
and  school  discipline  was  irksome  to  him,  as  he 
learned  more  rapidly  than  many  of  his  companions. 
Yet,  in  fact,  he  did  not  apply  himself  closely  to 
study  until  he  commenced  the  study  of  medicine, 
which  he  took  up  with  great  earnestness. 

During  his  youth  he  was  very  fond  of  drawing, 
and  was  very  clever  with  tools,  traits  which  in  after 
life  were  of  the  greatest  service  to  him. 

His  inclination  toward  the  study  of  medicine  as 
a  profession  was  first  shown  while  at  Haverford 
College  with  Mr.  Chase,  when  he  wrote  to  a  member 
of  his  family  of  his  desire  to  study  medicine,  and 
asked  to  have  a  skull  sent  to  him,  adding  that  he 
"  would  like  one  with  all  the  teeth." 

Eminently  fitted  by  nature,  environment,  and 
education  for  the  medical  profession,  the  decision 


Q  MEMOIR  OF  A.  S.  ROBERTS. 

having  once  been  made,  he  devoted  himself  to  its 
study  with  all  the  energies  of  his  soul,  as  Gross  has 
said  of  Valentine  Mott :  "  He  loved  surgery  as  his 
mistress,  and  his  constancy  merited  all  the  favors 
which  she  so  lavishly  showered  upon  him." 

With  a  decidedly  artistic  taste,  his  leaning  was 
toward  the  study  of  architecture,  and  particularly 
drawing  and  similar  studies,  and  he  told  me  his 
tendency  always  was  in  favor  of  the  profession  of 
a  railroad  engineer,  especially  bridge-building. 

There  is  no  doubt  that  if  he  had  decided  to  enter 
the  profession  of  engineering  his  success  would 
have  been  equally  as  great  as  in  the  one  which  he 
chose.  In  this  connection  the  incident  of  Dr. 
Physick  recurs  to  us  as  being  a  circumstance  of 
similar  kind.  Dr.  Physick's  father  was  a  silver- 
smith, and  it  was  always  the  son's  regret  that  his 
father  would  not  permit  him  to  follow  in  his  foot- 
steps, although,  as  every  one  knows,  Dr.  Physick 
was  the  most  distinguished  surgeon  of  his  time. 

Dr.  Roberts  was  particularly  fortunate  in  the 
choice  of  a  preceptor.  It  was  in  the  office  of  Dr. 
Keen  that  young  Roberts  first  became  fully  inspired 
with  that  love  for  his  profession  which  ever  after- 
ward was  a  remarkable  feature  of  his  career. 

Henceforth  forever  his  ambition  was  not  simply 
to  be  the  doctor,  as  Pope  would  have  it, 

"Sole  judge  of  truth  in  endless  error  hurled, 
The  glory,  jest,  and  riddle  of  the  world," 

but  to  be  a  great  surgeon. 

To  be  a  great  surgeon  is  an  ambition  for  which 


INTRODUCTION.  7 

any  one  might  strive,  for,  with  Gross,  I  unhesitat- 
ingly assert,  without  fear  of  successful  contradiction, 
that  it  "  requires  as  much  intellect,  talent,  genius, 
and  knowledge  to  form  a  great  surgeon  as  it  does 
to  form  a  great  lawyer,  judge,  divine,  general,  or 
statesman." 

Dr.  William  W.  Keen  at  this  time  was  laying  for 
himself  the  foundation  of  the  enviable  reputation 
that  he  now  enjoys.  From  the  introductory  address 
delivered  by  Dr.  Keen  in  his  course  of  lectures  on 
anatomy  at  the  Philadelphia  School  of  Anatomy 
the  following  year,  we  gain  some  idea  of  the  charac- 
ter of  the  instruction  given  by  him  at  that  time. 
As  the  successor  of  Dr.  Agnew  in  the  old  Philadel- 
phia School  of  Anatomy,  he  demonstrated  not  only 
his  thorough  knowledge  of  this  important  branch  of 
medicine,  but  also  his  ability  to  instruct  students, 
and  moreover  to  entertain  them,  by  his  delightful  de- 
scriptions of  the  early  history  of  practical  anatomy. 

In  addition  to  the  regular  winter  term  in  the 
Medical  Department  of  the  University  of  Pennsyl- 
vania, Dr.  Roberts  attended  three  full  spring  courses 
of  lectures  in  this  school,  and  was  graduated  there- 
from on  March  12,  1877. 

His  fondness  for  the  study  of  pathology  led  him 
early  to  use  the  microscope  in  the  pursuit  of  his 
studies,  a  somewhat  unusual  procedure  in  those 
days,  but  by  virtue  thereof  he  secured  honorable 
mention  for  his  thesis,  and  subsequently  became 
Assistant  Demonstrator  of  Histology. 

Having  determined  to  enter  the  profession  of  medi- 
cine, Dr.  Roberts  began  his  study  with  all  the  energy 


8  MEMOIR  OF  A.  S.  ROBERTS. 

of  his  young  manhood.  Roused  by  the  earnestness 
of  his  preceptor,  Dr.  "W.  W.  Keen,  and  surrounded 
by  the  spirit  of  enthusiasm  everywhere  rife  in  the 
University,  his  progress  was  marked. 

To  thoroughly  understand  the  influence  of  the 
times,  one  must  mark  the  conditions  of  the  Univer- 
sity at  the  entrance  of  Dr.  Roberts. 

The  Medical  Department  of  the  University  con- 
tained at  the  time  bat  seven  major  chairs. 

The  spirit  of  progress  and  development  that  char- 
acterized the  institution  from  its  beginning,  in  1740, 
as  a  charitable  school  manifested  itself  in  marked 
epochs  of  change. 

Dr.  Roberts  entered  the  study  of  his  profession 
in  1873,  when  every  department  throbbed  with  latent 
life,  only  wanting  the  accepted  time  to  manifest  itself 
in  marked  and  brilliant  change.  Daily  contact  with 
this  spirit  through  the  formative  years  of  his  devel- 
opment assured  the  permeation  of  his  character  with 
the  same  animation  that  prompted  the  actions  of  his 
preceptors. 

Every  energy  of  his  young  manhood,  every  ambi- 
tion of  his  life,  every  demand  of  his  intellectual 
nature  found  its  response  in  the  spirit  of  the  insti- 
tution during  those  years. 

Prominent  among  those  who  toiled  and  waited 
stood  Dr.  William  Pepper. 

Recounting  the  years  of  progress,  and  identified 
with  the  University,  he  reviewed  the  past  and  fore- 
cast the  future.  In  his  most  interesting  address 
upon  "  Higher  Medical  Education — the  True  Inter- 
est of  the  Public  and  Profession,"  he  recounts  the 


INTR  OD  TJCTION.  9 

long  heroic  struggle  of  the  friends  of  the  University 
to  obtain  an  ideal  standard.  Weeks  and  months  had 
lengthened  into  years,  hope  had  given  place  to  dis- 
appointment, effort  had  ended  in  discouragement 
times  over,  before  the  glad  day  of  victory  had 
dawned. 

Dr.  Roberts  took  up  his  life  work  at  this  auspi- 
cious time,  his  year  of  graduation,  1877. 

This  year  marked,  according  to  Dr.  Pepper : 

1.  The  establishment  of  a  preparatory  examina- 
tion. 

2.  The  lengthening  of  the  period  of  collegiate 
studies  to  at  least  three  full  years. 

3.  The  careful  grading  of  the  course. 

4.  The  introduction  of  ample  practical  instruction 
of  each  student  both  at  the  bedside  and  in  labora- 
tories. 

5.  The  establishment  of  fixed  salaries  for  the 
professors,  so  that  they  would  no  longer  have  any 
pecuniary  interest  in  the  sizes  of  their  classes. 

Such  standards  maintained  meant  new  men  in 
new  places.  The  realms  of  science  with  their  hidden 
treasures  awaited  the  enthusiastic  student  explorer 
who  brought  to  this  undiscovered  country  intelli- 
gence, enthusiasm,  and  patient  perseverance. 

The  few  noble  lives  that  had  uplifted  the  standard 
of  advance  were  reinforced  by  able  men  in  the  new 
lines  that  diverged  from  their  original  centre.  The 
number  in  the  Faculty  was  increased,  a  long  list  of 
clinical  instructors,  demonstrators,  and  lecturers 
was  added.  Faculties  of  departments  increased 
with  each  advance.     Enthusiasm  spread  from  the 


10  MEMOIR  OF  A.  S.  ROBERTS. 

council  chambers  of  faculty  and  trustee  conferences 
to  the  students  in  the  amphitheatre.  The  stimulus 
to  mental  activity  that  did  not  scorn  the  drudgery 
of  toil,  nor  ignore  the  opportunities  of  daily  doing, 
developed  from  the  pupils  men  who  became  in  turn 
leaders  in  other  circles,  representatives  of  the  new 
developments  and  expressions  of  the  ideas  of  their 
Alma  Mater.  Little  by  little  the  alpine  height  of 
excellence  was  attained  until  the  University  stood 
peer  with  other  institutions  of  acknowledged  emi- 
nence. An  expression  of  the  higher  manifestation 
of  her  influence  was  exemplified  when  at  her  instance 
the  State  Board  of  Examiners  was  suggested,  and 
again  the  profession  felt  the  fortifying  bulwark  of 
her  power.  Standards  of  excellence  were  demanded 
that  should  protect  alike  physician  and  patient. 

In  the  midst  of  this  consuming  energy  Dr.  Roberts 
stepped  into  the  arena  of  the  profession,  full  of  en- 
thusiasm and  culture,  proud  to  have  the  lines  of  life 
fall  to  him  in  an  hour  of  accepted  progress.  Stimu- 
lated to  action,  he  would  at  once  do  credit  to  his 
profession  and  to  his  Alma  Mater  who  conferred 
his  degree.  One  cannot  wonder  that  then  to  him 
came  the  ambition  that  would  pay  tribute  to  the 
power  that  had  placed  him  at  once  upon  a  plane  of 
advanced  thought  and  enrolled  his  name  among 
her  instructors.  To  him  it  was  not  an  ambition  to 
find  place  amongst  institutions  that  "  sprung  up  as 
mushrooms  in  a  night,"  but  he  toiled  to  be  worthy 
at  once  of  position  in  his  profession  and  University. 

The  class  of  '77,  in  which  Dr.  Roberts  graduated 
from   the   University  of  Pennsylvania,  contained 


INTE  OD  UGTION.  1 1 

several  men  who  have  since  distinguished  them- 
selves in  the  different  branches  of  their  profession. 
Among  them  we  notice  the  names  of  James  M. 
Anders,  Joseph  Price,  Matthew  N.  Oyer,  Francis 
X.  Dercum,  Henry  F.  Formad,  Thomas  H.  Fenton, 
Isaac  C.  Gable,  Herman  Haupt,  Jr.,  William  Hob- 
son  Heath,  William  C.  Hollopeter,  Rush  S.  Huide- 
koper,  Fairfax  Irwin,  John  H.  Musser,  J.  Wilkes 
O'Neil,  Andrew  J.  Parker,  and  George  A.  Piersoll. 

In  1877  he  served  in  the  Emergency  Corps  of  the 
State  militia  in  the  coal  region  riot  of  Pennsylvania 
as  volunteer  in  the  First  Troop,  Philadelphia  City 
Cavalry,  being  assistant  to  Dr.  William  G.  Porter, 
surgeon  to  the  First  Brigade,  1ST.  G.  P.  In  this 
capacity  he  served  in  the  West  Penn  Hospital, 
Pittsburg,  being  later  removed  with  the  troops  to 
Scranton. 

Immediately  upon  his  graduation  from  the  Uni- 
versity of  Pennsylvania  he  was  elected  to  the  posi- 
tion of  resident  physician  to  the  Blockley  Hospital 
(which  position  he  accepted  later),  where  he  served 
his  full  term  and  made  the  acquaintance  of  the 
members  of  the  staff,  who  were  afterward  of  great 
service  to  him  and  whose  colleague  he  soon  after- 
ward became,  being  very  earl}7  appointed  surgeon 
to  this  institution.  At  the  suggestion  of  Dr.  S. 
Weir  Mitchell,  he  decided  to  turn  his  attention  to 
orthopedic  surgery  as  a  specialty.  With  this  in 
view,  he  became  resident  physician  in  the  New  York 
Orthopedic  Hospital,  then,  as  at  the  present  time, 
under  the  care  of  Dr.  Newton  M.  Shaffer,  surgeon 
in  charge.     The  influence  of  this  training  is  shown 


12  MEMOIR  OF  A.  S.  ROBERTS. 

throughout  his  work  in  this  special  department  of 
surgery  which  he  adorned  with  so  much  brilliancy. 
For  two  years  he  practised  in  this  institution.  Hav- 
ing in  his  mind  the  old  couplet, 

"A  little  knowledge  is  a  dangerous  thing; 
Drink  deep,  or  taste  not  the  Pierian  spring," 

he  returned  time  and  again  to  this  fountain  of  knowl- 
edge, each  visit  seeming  to  add  renewed  energy  and 
skill  to.  this  promising  surgeon. 

With  a  view  to  practising  his  profession  in  Phila- 
delphia, he  opened  an  office  at  133  South  Fifteenth 
Street,  and  at  once  attached  himself  to  several  hos- 
pitals in  the  capacity  of  assistant  surgeon.  Almost 
immediately  he  was  appointed  Visiting  Surgeon  to 
the  Philadelphia  Hospital,  Surgeon  to  the  Episcopal 
Hospital  Out-Patient  Department,  and  Instructor 
in  Orthopedic  Surgery  in  the  University  of  Pennsyl- 
vania. These  appointments  (with  occasional  visits 
to  other  hospitals,  in  consultation  with  other  sur- 
geons) occupied  his  time  very  fully  and  added 
greatly  to  his  amount  of  knowledge  and  his  success 
in  this  special  department. 

Through  his  personal  exertions  the  orthopedic 
shop  of  the  University  Hospital  was  organized,  a 
building  erected  for  the  purpose  and  thoroughly 
equipped  at  an  expense  of  nearly  $2000.  The  con- 
tin  nation  of  the  usefulness  of  this  shop,  and  the 
furnishing  of  free  apparatus  to  indigent  persons, 
have  been  secured  in  perpetuity  by  the  endowment 
by  members  of  his  family  of  the  A.  Sydney  Roberts 
Apparatus  Fund. 


INTB  OD  UCTION.  13 

This  was  the  first,  and  is  still  the  only  shop  of  its 
kind  connected  with  a  medical  college  hospital.  Its 
continued  usefulness  proves  the  foresight  and  wis- 
dom of  Dr.  Roberts' good  judgment  in  establishing  it. 

It  was  at  this  time  that  my  personal  knowledge 
of  Dr.  Roberts  began,  and  during  those  happy  days 
when  I  "  walked  the  boards "  of  the  Philadelphia 
and  Presbyterian  Hospitals  in  company  with  my 
preceptor,  Dr.  William  G.  Porter,  I  had  an  oppor- 
tunity of  seeing  Dr.  Roberts  at  work  in  these 
institutions.  I  was  at  once  impressed  with  his  thor- 
oughness, his  grasp  of  the  subject,  and  the  success 
he  obtained  in  the  treatment  of  this  neglected 
branch  of  surgery.  The  impressions  then  gained 
were  only  intensified  by  more  close  association  with 
him  in  after  years. 

His  experiences  at  the  different  hospitals  led  him 
early  to  desire  to  be  a  teacher.  The  occasion  soon 
offered  itself  in  lectures  delivered  at  the  University 
of  Pennsylvania  and  in  the  course  of  clinical  lec- 
tures which  he  delivered  at  Blockley  upon  ortho- 
pedic surgery,  the  latter  being  the  first  clinical 
lectures  ever  delivered  upon  the  subject  in  Phila- 
delphia. 

As  a  teacher  he  was  thorough,  clear,  and  impres- 
sive. Without  any  effort  at  rhetorical  display,  he 
impressed  the  students  at  once  with  his  thorough 
knowledge  of  the  subject  and  of  his  desire  to  impart 
freely  to  them  all  the  knowledge  he  had  acquired. 

His  diagnosis  was  accurate,  and  his  selection  of 
the  proper  treatment  or  apparatus  was  made  with 
the  greatest  consideration  for  the  comfort  and  speedy 


14  MEMOIR  OF  A.  S.  ROBERTS. 

recovery  of  the  patients.  If  an  operation  was  re- 
quired the  necessity  for  it  was  stated  in  such  a 
manner  that  it  was  never  refused. 

His  practice  was  principally  among  the  better 
class  of  society,  and  much  of  it  came  to  him  from 
consultations  with  other  physicians  and  through  the 
recommendation  of  Dr.  S.  Weir  Mitchell,  Dr.  Wil- 
liam W.  Keen,  and  Dr.  Newton  M.  Shaffer,  all  of 
whom  indorsed  him  in  most  unqualified  manner. 
His  practice  was  active  during  the  short  time  he 
was  engaged  in  it,  and  there  is  no  doubt  that  had 
he  continued  he  would  have  acquired  a  large  clien- 
tele and  a  lucrative  income  from  this  source.  While 
his  practice  was  largely  among  the  better  and  more 
influential  classes,  he  was  as  kind  to  the  poor  as  to 
the  rich,  and  I  have  known  a  mother,  who  was  too 
frail  to  carry  her  child  to  the  hospital,  advised  by 
him  to  bring  it  to  his  office  to  be  treated  cheerfully 
and  thoroughly  without  a  fee.  Among  his  papers 
were  found  many  letters  from  poor  patients  express- 
ing their  gratitude,  and  many  of  the  nurses  on  duty 
at  the  Philadelphia  Hospital  during  Dr.  Roberts' 
service  have  remarked  his  kind  manner  to  the  des- 
titute. 

At  this  time  he  employed  assistants  for  certain 
portions  of  his  work.  A  large  number  of  black  and 
white  sketches  and  colored  drawings  were  made, 
casts  were  taken,  and  his  hospital-books  were  kept 
most  accurately  by  Dr.  S.  R.  Jenkins,  now  of  Char- 
lottetown,  Prince  Edward's  Island,  Canada;  Dr. 
William  S.  Johnson,  now  of  Germantown,  and  my- 
self.   His  manner  toward  his  assistants  was  always 


INTR  OB  UCTION.  \  5 

kindly  and  considerate,  and  on  one  occasion  I  was 
myself  the  recipient  of  a  trip  South  through  his 
interest  in  my  physical  condition. 

Although  his  career  was  brief,  he  performed  a 
number  of  important  and  difficult  operations  upon 
patients  committed  to  his  care.  These  were  always 
done  in  a  most  thorough  and  skilful  manner,  and 
every  detail  was  carefully  thought  out  before  any 
operation  was  undertaken.  His  instruments  and 
apparatus  of  all  kinds  were  of  the  finest,  and  he 
used  them  as  freely  in  the  treatment  of  the  poorest 
individuals  as  in  operations  upon  the  more  wealthy 
patients.  Soon  after  his  election  to  Blockley  he 
several  times  performed  osteotomy  of  the  femur 
(Mace wen's  operation)  with  full  antiseptic  precau- 
tion and  with  perfect  results.  Excision  of  the  knee 
he  frequently  performed,  as  well  as  tenotomies  of  all 
kinds,  after  which  latter  operations  he  usually  em- 
ployed an  apparatus  of  some  kind  specially  prepared 
for  the  patient. 

As  a  surgeon,  he  was  cool,  deliberate,  and  thor- 
ough, and  his  success  was  uniform  and  phenomenal. 

His  genius  was  dazzling,  burning  ever  brighter 
with  a  steady  flame.  His  career,  like  that  of  Bis- 
chat,  was  meteoric,  brief,  but  brilliant;  and  if  the 
measure  of  talent  and  genius  be  success,  the  esti- 
mate placed  upon  his  career  must  be  great.  The 
limits  were  boundless,  but  few  men  ever  attain  the 
topmost  round  of  the  ladder  of  fame,  and  genius 
must  add  time  to  her  industry,  no  matter  how  steady 
and  persistent. 

Some  of  his  lectures  before  the  students  at  the 


16  MEMOIR  OF  A.  S.  ROBERTS. 

Philadelphia  Hospital  were  afterward  published  in 
book  form,  and  comprised  two  upon  club-foot,  two 
upon  knock-knee,  and  one  upon  flat-foot,  with  a 
description  of  a  new  plantar-spring  for  its  relief. 
His  writings  include  a  complete  article  on  Pott's 
disease  of  the  spine,  in  Keating's  "  Encyclopaedia," 
vol.  iv,  a  most  comprehensive  article.  In  conjunc- 
tion with  Dr.  Samuel  Ketch,  of  New  York,  he 
wrote  an  article  upon  club-foot  in  Buck's  "Reference 
Handbook  of  the  Medical  Sciences."  This  article 
contains  the  best  bibliography  upon  this  subject  ex- 
tant, and  I  doubt  if  anything  will  ever  be  written  to 
compare  with  it.  In  1 884  he  read  a  paper  before  the 
Pennsylvania  State  Medical  Society  upon  "  Chronic 
Articular  Ostitis  of  the  Knee-joint,"  with  a  descrip- 
tion of  a  new  mechanical  splint,  which  was  published 
in  the  "  Medical  News,"  on  July  26,  1884.  Among 
other  articles  written  at  this  time  was  one  upon  the 
spinal  arthropathies,  published  in  the  "  Medical 
News,"  February  18,  1885,  which  attracted  con- 
siderable attention.  The  photographs  collected, 
illustrative  of  this  subject,  but  not  published  till 
subsequently,  comprise  the  best  group  of  photo- 
graphs upon  this  subject  that  has  ever  been  col- 
lected. About  this  time  he  reported  a  case  of 
deformity  of  the  forearm  and  hands,  which  was 
published  in  the  "Annals  of  Surgery,"  in  Feb- 
ruary, 1886.  This  contains  the  pictures  of  the 
splint,  modified  from  that  of  Dr.  Shaffer,  of  New 
York,  and  employed  by  Dr.  Roberts  in  the  treat- 
ment of  knee-joint  diseases.  After  his  retirement 
from  practice  he  published  a  volume  of  selections 


INTR  OD  UGTION.  1 7 

from  literature,  which  he  called  "In  and  Out  of 
Book  and  Journal,"  which  was  published  by  Lipp- 
incott  &  Company,  and  had  an  extensive  sale. 

His  writings  are  not  as  large  as  one  would  expect 
considering  the  amount  of  work  which  he  did.  This 
is  probably  due  to  his  dislike  to  writing  and  his 
attention  to  more  practical  matters.  His  writings 
are  of  the  highest  order,  and  reflect  great  credit  upon 
him  for  the  amount  of  research  and  the  quality  of  the 
matter  contained. 

He  reported  many  operations  before  the  Patho- 
logical Society,  and  exhibited  specimens,  several  of 
which  I  now  have  in  my  possession. 

He  was  a  Fellow  of  the  College  of  Physicians  of 
Philadelphia,  a  Fellow  and  Yice-President  of  the 
American  Orthopedic  Association,  a  member  of  the 
Philadelphia  County  Medical  Society,  the  Patho- 
logical Society,  the  Neurological  Society,  the  State 
Medical  Society,  the  American  Medical  Society,  and 
a  delegate  to  the  International  Medical  Congress  in 
London. 

In  personal  appearance  Dr.  Roberts  was  of  me- 
dium height,  strongly  and  compactly  built,  of  a 
florid  temperament,  high  forehead,  good  features, 
and  carrying  with  him  the  impression  of  great  re- 
serve force.  His  manner  was  that  of  a  cultured 
gentleman,  and  his  associations  such  as  would  de- 
velop a  manner  which  was  at  once  kind  and  firm. 
His  characteristic  was  a  particular  sensitiveness. 
His  disposition  was  quick  and  impulsive,  but  kind 
and  forgiving ;  a  warm  and  faithful  friend.  With 
truth  it  could  be  said  that  his  friendship  was  eternal. 

2 


18  ME  MO  IE  OF  A.  S.  ROBERTS. 

The  estimate  of  Dr.  John  H.  Musser,  his  most 
intimate  friend,  is  so  thoroughly  descriptive  of  Dr. 
Roberts'  best  qualities,  that  I  take  the  liberty  to 
quote  it  in  full.  Speaking  of  his  friend  Roberts,  he 
writes : 

"  Fortunately  for  me,  our  friendship  was  not  alone 
professional.  On  two  occasions  I  travelled  in  Europe 
with  him,  and  on  several  occasions  in  this  country. 
Here  it  could  be  seen  he  was  a  man  of  affairs.  This 
was  the  least,  however.  I  constantly  marvelled  at 
his  wide  acquaintanceship  with  the  fine  arts — paint- 
ing and  painters,  sculpture  and  sculptors,  architec- 
ture, etc.  He  was  familiar  with  the  development  of 
art  in  all  its  phases  and  of  all  its  schools.  His 
early  training  in  painting  taught  him  to  be  an  excel- 
lent critic.  He  could  criticise  accurately  the  color- 
ing or  appreciate  the  value  of  the  thought  in  the 
work  of  art  and  its  development.  Furniture,  tapes- 
tries, decorations,  metal  work,  glass,  and  china  had 
been  the  subject  of  study,  and  their  relations  to 
industrial  development.  After  a  visit  with  profit 
and  pleasure  to  an  art  gallery,  a  museum,  a  palace 
with  its  art  treasures,  it  was  interesting  and  marvel- 
lous to  go  with  him  to  some  great  mechanical  works 
or  some  piece  of  engineering  and  see  with  what 
rapturous  delight  he  appreciated  it,  and  with  what 
knowledge  of  technical  detail  he  could  explain  the 
mysteries  of  the  mechanism.  When  I  tell  you  he 
was  a  critic  of  no  mean  order,  and  a  man  of  exqui- 
site taste,  with  an  extraordinary  appreciation  of  the 
beautiful  in  art,  }Tou  can  readily  see  how  enjoyable 
a  companion  he  was. 


INTB  OB  TJCTION.  1 9 

"  Roberts  also  loved  nature,  and,  whether  on  the 
boundless  ocean,  in  the  mountains  of  Switzerland, 
in  the  pastoral  scenes  of  England,  or  the  rougher 
charms  of  Scotland,  he  was  always  full  of  enthu- 
siasm and  appreciation  of  the  beauties  of  nature. 
Roberts's  fondness  for  animals  led  him  to  study 
them,  and  he  was  an  excellent  judge  of  horse,  of  cow, 
of  dog.  He  was  fond  of  out-door  sports,  and  was 
an  expert  in  shooting,  rowing,  and  the  like.  How 
almost  unlimited  were  his  sympathies,  and  how 
boundless  was  his  knowledge  !  He  had  a  most  ex- 
cellent memory,  and  the  history  of  the  countries  we 
travelled  through  was  at  his  fingers'  ends.  This 
added  to  the  charm  of  our  travels. 

"  Curiously,  although  of  broad  culture  Dr. 
Roberts  was  not  a  linguist.  Language  was  not 
mastered  easily  by  him,  although  his  writings  show 
he  was  a  master  of  English ;  his  conversational 
powers,  that  he  could  command  it  at  will. 

"Roberts  appreciated  music.  I  recall  the  delights 
he  showed  at  the  music  of  the  evening  service  at 
Cologne  Cathedral.  He  was  not  as  familiar  with  the 
literature  and  development  of  this  art  as  others." 

Dr.  Samuel  Ketch,  another  personal  friend  of  Dr. 
Roberts,  has  paid  tribute  to  his  memory  in  his 
Presidential  Address,  published  in  the  last  volume 
(1897)  of  the  "  Transactions  of  the  American  Ortho- 
pedic Association." 

His  office  was  neat,  plain,  and  well  arranged,  and 
one  could  see  at  a  glance  that  it  was  the  office  of  a 
practical  and  progressive  surgeon.  In  office  details 
his    early   education    and    business    qualities  were 


20  MEMOIR  OF  A.  S.  ROBERTS. 

everywhere  conspicuous.  His  horses  and  carriages 
were  neat  and  elegant  to  a  degree.  His  office  hours 
were  from  8  to  11,  and  were  always  promptly  kept. 
His  stationery  was  always  the  same  Imperial  Bond, 
of  a  beautiful  marine-blue  tint,  and  his  penmanship 
had  a  style  and  character  that  were  unmistakable. 

While  in  the  enjoyment  of  everything  that  would 
tend  to  make  him  happy,  and  with  the  prospect  of 
a  great  and  growing  future  before  him,  his  health 
began  to  fail,  and  he  was  compelled  to  retire  from 
practice  in  1888  and  seek  change  in  the  country. 
In  resigning  his  positions  at  the  different  hospitals 
(two  of  which  it  was  my  privilege  to  receive),  a  sin- 
cere regret  was  expressed  in  his  resignation  that  he 
was  compelled  to  give  up  practice  at  this  time. 

In  his  letter  of  November  23,  1888,  to  me,  in 
speaking  of  resigning  his  position  as  instructor  in 
orthopedic  surgery,  he  evinced  his  keen  interest  in 
the  future  progress  of  conservative  orthopedic  sur- 
gery. "  I  have  to-day,"  he  writes,  "  sent  to  the 
University  and  to  the  University  Hospital  my  resig- 
nations, and  hope  you  may  be  an  applicant  for  the 
positions  I  vacate,  and  I  trust  that  if  you  secure  the 
appointments  you  will  push  the  work  in  the  interest 
of  conservative  orthopedy." 

Having  decided  to  retire  from  active  practice,  he 
gave  away  many  of  his  instruments,  the  most  expen- 
sive ones  to  his  personal  friend,  Dr.  William  G. 
Porter,  to  his  preceptor,  Dr.  William  W.  Keen,  and 
myself.  All  of  his  orthopedic  apparatus  and  all  of 
his  special  books  upon  orthopedic  surgery  were 
received  by  me  in  this  way,  and  my  indebtedness 


INTB  OD  UCTION.  21 

to  him  has  already  been  expressed  by  the  partial 
dedication  to  him  of  my  work  upon  orthopedic 
surgery.1 

Although  in  feeble  health  for  some  time,  his  death 
occurred  suddenly  and  unexpectedly,  at  Newport, 
on  August  17,  1896.  The  funeral  took  place  from 
his  late  residence,  at  Bala,  on  Thursday  morning, 
at  11  o'clock,  the  interment  being  private.  His 
earthly  remains  were  interred  in  the  family  vault 
at  Laurel  Hill  Cemetery. 

At  the  University  Club,  just  before  the  dinner, 
March  11,  1898,  when  a  guest  of  Dr.  De  Forest 
Willard  and  myself,  Dr.  Newton  M.  Shaffer  said  of 
his  friend  Dr.  Roberts,  "  Had  he  practised  until 
to-day,  his  reputation  would  have  been  national." 

Accidental  expressions  of  character  in  a  man's 
life  many  times  live  after  him  in  enduring  form. 
Near  the  home  of  his  ancestors,  at  the  side  of  the 
public  highway,  it  pleased  Dr.  Roberts  to  erect  a 
fountain  at  which  the  hurrying  traveller  might  pause 
and  drink. 

The  shadows  may  fall  and  shut  from  sight  familiar 
scenes,  the  passing  throng,  the  granite  fountain 
with  its  cooling  stream,  but  through  the  darkness 
unheeded  the  limpid  stream  flows  on  and  in  the 
morning  blesses  the  new  day. 

The  years  glide  on,  the  shadows  fall ; 

But  works  his  hands  have  wrought  live  on ! 

1  Treatise  on  Orthopedic  Surgery. 


CLUB-FOOT:    TALIPES. 


CLUB-FOOT:   TALIPES. 


Definition.  Under  the  generic  term  Club-foot, 
or  Talipes,  are  included  all  cases  of  deformity  of  the 
foot,  whether  on  an  antero-posterior  or  transverse 
plane,  and  which  are  presented  in  a  departure  from 
the  normal  relation  of  the  foot  to  the  leg  or  of  the 
foot  to  itself.  This  abnormal  relation  may  consist 
of  a  flexion,  extension,  inversion,  or  eversion. 

Synonyms.  Ger.,  Klumpfuss;  Lat.,  Pes  con- 
tortus;  Fr.,  Pied  hoi;  It.,  Piede  torto;  Sp.,  Pie 
truncado. 

Varieties.  Club-foot  is  most  conveniently  di- 
vided into  two  classes,  namely,  the  simple  and  com- 
pound, and  of  the  former  we  have  four  typical 
forms.  These  are  talipes  varus,  talipes  valgus, 
talipes  equinus,  and  talipes  calcaneus.  The  first 
form,  talipes  varus,  is  characterized  by  an  elevation 
of  the  inner  side  of  the  foot,  the  sole  being  turned 
inward  and  the  anterior  portion  of  the  foot  adducted. 
In  talipes  valgus,  its  opposite,  the  outer  side  of  the 
foot  is  raised  and  the  sole  everted.  Talipes  equinus 
presents  itself  as  an  elevation  of  the  heel,  the  foot 
being  in  a  position  of  extension,  the  patient  walking 
on  the  ball  of  the  foot.  In  talipes  calcaneus  the  toes 
are  raised,  the  foot  being  in  a  position  of  flexion, 
and  the  patient  walking  on  the  heel.    The  two  first- 


26 


MEMOIR  OF  A.  S.  ROBERTS. 


mentioned  deformities  occur  on  a  lateral,  the  two 
latter  on  an  antero-posterior  plane.  To  these  four 
simple  forms  some  authors  add  other  forms :  Talipes 
cavus,  where  the  arch  of  the  foot  is  increased,  and 
talipes  planus,  its  opposite,  where  the  sole  rests 
upon  the  ground,  the  arch  being  diminished.  Re- 
cently Shaffer,  of  New  York,  has  described  another 
class,  that  of  non-deforming  club-foot.  Any  com- 
bination of  the  simple  varieties  gives  us  the  com- 
pound form :  talipes  equino-varus  and  equino-valgus, 
and  calcaneo- varus  and  calcaneo- valgus.  Schemat- 
ically these  different  forms  may  be  pictured  as 
follows : 


'  Simple 


Varieties  .    -j  Compound 


I 


Other  forms , 


f  Lateral 

( Antero-posterior 

f  Equino- 

( Calcaneo-     . 

i  Cavus. 
Planus. 
Non-deforming. 


f  Varus. 
{  Valgus. 
|  Equinus. 
|  Calcaneus. 
]  Varus. 
{  Valgus, 
f  Varus. 
{  Valgus. 


Relative  Frequency.  In  obtaining  informa- 
tion concerning  the  relative  frequency  of  the  differ- 
ent forms,  much  difficulty  is  experienced,  owing  to 
the  different  nomenclature,  notably  for  varus  and 
equino-varus,  used  by  those  making  statistics  on 
the  subject.  From  Tamplin's  table,  published  in  the 
"London  Medical  Gazette"  for  October,  1851,  and 
covering  1780  cases  of  club-foot,  both  congenital 
and  acquired,  764  of  the  former  were  recorded  to 
101(5  of  the  acquired  form.  By  these  tables  it  is 
shown  that  by  far  the  larger  number  were  of  the 
acquired    variety,    the    proportion,    as    stated    by 


CLUB-FOOT:   TALIPES.  27 

Adams,  being-  as  3  :  2.  Of  the  congenital  variety, 
the  tables  show  a  preponderance  of  cases  of  talipes 
varus,  but  no  distinction  is  evidently  made  between 
the  simple  varus  and  the  compound  form,  talipes 
equino-varus.     The  tables  are  appended : 

Congenital. 

Cases. 

Talipes  varus 688 

Talipes  valgus 42 

Talipes  calcaneus .19 

Talipes  varus  of  one  foot  and  valgus  of  the  other.       15 

Total 764 

Of  the  688  cases  of  talipes  varus,  182  affected 
the  right  foot  only ;  138  affected  the  left  foot  only ; 
363  affected  both  feet,  and  5  cases  were  complicated 
with  other  deformities. 

Of  the  1780  cases,  1016  were  non-congenital ; 
999  were  distributed  as  follows  : 

Acquired. 

Cases. 

Talipes  equinus 401 

Talipes  valgus 181 

Talipes  equino-varus 162 

Talipes  calcaneus  and  calcaneo- valgus    .         .         ,110 

Talipes  equino-valgus 80 

Talipes  varus 60 

Talipes  varus  of  one  foot  and  valgus  of  the  other.        5 

Total 999 

Reeves,  in  an  experience  of  ten  years  at  the  Royal 
Orthopedic  Hospital,  London,  gives  equino-varus 
as  the  most  frequent  congenital  form,  and  also  states 
that  the  primitive  forms  of  club-foot  are  rare  as 
congenital  deformities.   Sayre,  in  his  work  on  "  Club- 


28  MEMOIR  OF  A.  S.  ROBERTS. 

foot,*'  and  also  in  the  article  in  his  work  on  "  Ortho- 
paedic Surgery  and  Diseases  of  the  Joints,"  gives  no 
statistics  as  to  the  relative  frequency,  but  states 
that  the  simple  forms  of  club-foot  are  very  rare,  the 
deformity  being  nearly  always  a  combination  of 
two  forms.  F.  Busch  gives  equino-varus  as  the 
most  frequent  form.  Duval  has  recorded  1000 
cases  of  club-foot,  and  of  these  574  were  congenital ; 
364  of  these  were  in  males  and  210  in  females.  His 
statistics  as  to  relative  frequency  are  very  valuable, 
and  are  as  follows  : 


Cases. 

Boys. 

Girls. 

Equinus  and  equino-varus 

417 

215 

202 

Varus        .... 

532 

302 

230 

22 

14 

8 

Calcaneus 

9 

6 

3 

Extreme  calcaneus  . 

20 

13 

7 

Adams,  in  his  work  on  "  Club-foot,"  gives  talipes 
equinus  as  by  far  the  most  frequent  non-congenital 
deformity.  Little  states  that  he  has  seen  two  cases 
of  congenital  equinus,  as  does  also  Brodhurst. 
Tamplin  discredits  entirely  the  congenital  origin  of 
pure  equinus,  and  states  that  he  had  not  seen  a  case. 
Detmold  has  reported  167  cases  of  club-foot,  and 
states  that  of  these  93  occurred  in  both  feet.  Gross 
remarks  that  the  congenital  variety  rarely  affects 
both  feet  in  an  equal  degree ;  that  in  his  own  expe- 
rience the  single  forms  were  considerably  greater  in 
number.  Lannelongue  has  collected  statistics  at 
the  Maternity  Hospital  (Paris)  covering  a  period 
of  ten  years,  from  1858  to  1867  inclusive.  He  has 
shown  that  in  15,229  births,  8  children  were  born 
with  club-foot,  which  gives  a  proportion  of  about  1 


CLUB-FOOT:   TALIPES.  29 

case  in  1903  births.  As  yet  the  influences  of  climate 
and  social  position  have  not  been  determined.  It 
probably  occurs  more  frequently  among  the  poorer 
classes. 

From  the  foregoing  statistics,  which  have  been 
considered  sufficient,  the  following  facts  may  be 
deduced : 

1.  The  greater  relative  frequency  in  males. 

2.  That  the  varus  types  are  the  most  frequent. 

3.  That  the  right  foot  is  affected  more  frequently 
than  the  left. 

4.  That  both  feet  are  more  frequently  affected 
than  a  single  one. 

5.  That  the  purely  primitive  forms  are  rare. 
Etiology.     There  are  two  classes  of  club-foot, 

namely,  the  congenital  and  acquired,  and  in  study- 
ing their  etiology  we  shall  consider  the  former  class 
first.  In  no  department  of  medicine  is  there  so 
much  that  is  mysterious  and  unexplained  as  is 
involved  in  the  causation  of  deformities  of  congeni- 
tal origin.  From  earliest  times  they  have  been  the 
subject  of  a  vast  amount  of  labor  and  inquiry,  and 
while  these  investigations  have  resulted  in  many 
speculations  and  a  few  facts,  the  theories  established 
by  them  still  leave  much  to  learn  concerning  the 
real  origin  of  this  class  of  cases.  The  question  is 
beset  with  difficulties  from  the  onset,  from  the  fact 
that  the  life  of  the  foetus  in  utero  is  not  subject 
to  any  direct  scientific  means  of  investigation,  and 
we  are  compelled  to  study  the  subject  from  such 
aids  as  comparative  physiology,  embryological  data, 
and  post-partum  existence  and  diseases  furnish  us. 


30  MEMOIR  OF  A.  S.  ROBERTS. 

Could  we  positively  admit  the  question  of  diseases 
of  the  fetus,  such  as  pertain  to  post-partum  exist- 
ence, the  problem  would  be  relatively  simple.  Many 
authors,  notably  Little,  have,  from  the  similarity  in 
the  deformities  of  the  congenital  and  acquired  para- 
lytic forms,  assumed  this  ground.  Outside  of  the 
similarity  in  the  appearance  of  the  deformities,  this 
view  is  not  tenable,  for  it  has  not  been  proven  that 
a  foetal  myelitis  or  meningitis  has  existed.  The 
microscope  has  not,  as  yet,  demonstrated  changes 
taking  place  in  the  foetal  brain  or  cord,  such  as 
occur  in  infantile,  cerebral,  or  spinal  paralysis.  An 
electrical  examination  shows  very  markedly  differing 
reactions  in  the  muscles  of  the  two  forms,  and  pa- 
tients suffering  with  congenital  club-foot  can,  by 
the  exercise  of  volition,  use  the  muscles  of  the  leg 
and  foot,  while  such  is  not  the  case  in  the  acquired 
form.  These  differences,  together  with  the  external 
appearances  of  the  parts  affected — the  one  cold, 
flaccid,  and  atrophied;  the  other  of  normal  surface 
temperature,  plump,  and  of  rounded  contour — indi- 
cate an  entirely  different  causation  of  the  deformity. 

Heredity,  with  its  mysterious  influences,  physical 
and  psychical,  also  enters  into  this  complex  ques- 
tion, and  is  undoubtedly  a  factor  in  the  etiology  of 
many  cases.  Did  space  permit,  many  instances 
might  be  quoted  as  illustrative  of  this.  From  these 
we  can  as  yet  deduce  no  better  explanation  of  its 
influence  than  the  transmission  of  personal  config- 
uration. 

Arrest  of  development  has  also  been  assigned  as 
a  cause  for  the  production  of  congenital  club-foot. 


CLUB-FOOT:   TALIPES.  31 

Although  many  cases  occur  in  which  there  is  a 
coexistence  of  such  deformities  as  spina  bifida, 
hare-lip,  and  cleft  palate  with  club-foot,  yet  the  feet 
themselves  show  no  arrest  of  development,  but  only 
the  same  change  of  plane  as  is  shown  in  the  cases 
born  without  these  coexisting  deformities.  Changes 
in  the  tarsal  bones,  principally  the  astragalus  and 
os  calcis,  have  been  described  by  many  authors, 
but  by  none  more  thoroughly  than  by  Adams  and 
Hueter.  These  changes  consist  in  alterations  in 
the  form  and  plane  of  these  bones,  but  they  are  by 
no  means  constant,  and  differences  of  opinion  are 
held  as  to  their  being  primary  or  causative,  or  secon- 
dary, as  results  of  the  deformity  itself.  The  most 
recent  investigations  tend  to  maintain  the  latter 
theory.  It  has  also  been  found  that  use  of  the 
deformed  foot  largely  increases  the  malposition  and 
form  of  the  tarsal  bones.  A.  Luecke  also  considers 
the  osseous  structure  as  the  seat  of  primary  lesion 
in  club-foot.  He  and  others  have  shown  that  at  a 
a  certain  period  all  foetuses  are  club-footed,  and 
Luecke  claims  that  by  the  constant  movement  of 
the  child  in  utero  the  articular  surfaces  are  so 
modified  by  the  attrition  produced  as  to  enable  the 
child's  feet  to  assume  a  normal  position  before  birth; 
any  interference  with  these  movements  would,  how- 
ever, prevent  this  attrition,  and  the  child  would  be 
born  club-footed.  Against  this  ingenious  theory  it 
may  be  argued  that  use  increases  the  deformity 
after  birth.  Why  it  should  act  differently  before  is 
not  easy  to  understand.  We  also  know  that  in 
acquired  cases,  such  as  are  due  to  spastic  paralysis, 


32  MEMOIR  OF  A.  S.  ROBERTS. 

for  instance,  want  of  use  does  not  so  change  the 
articular  surfaces  as  to  cause  permanent  club-foot, 
tenotomy  in  many  cases  restoring  the  foot  to  its 
form  and  function.  Perhaps  of  all  the  theories 
advanced,  that  which  ascribes  congenital  club-foot 
to  abnormal  intra-uterine  pressure,  due  to  lack  of 
amniotic  fluid,  has  received  the  largest  number  of 
adherents.  Most  of  the  older  writers,  and  many 
modern  ones,  prominently  Volkmann,  Kocher,  Vogt, 
Banga,  and  Parker,  are  among  its  most  noted  advo- 
cates. Here  it  is  maintained  that  the  foetal  foot 
is  permanently  fixed  in  one  position  by  the  intra- 
uterine pressure,  and  consequently,  at  birth,  the  child 
is  club-footed.  It  has,  very  reasonably,  been  argued 
against  this  view,  that  if  a  decreased  amount  of 
amniotic  fluid  and  consequent  abnormal  pressure 
were  productive  of  club-foot,  other  organs  which 
had  been  subjected  to  the  same  pressure  would  also 
be  deformed.  Yet  such  is  not  the  fact,  clubbed 
hands,  legs,  and  thighs  being  among  the  rarest  of 
deformities,  very  seldom  complicating  the  pedal 
malformation.  It  has  also  been  shown  that  many 
children  have  been  born  club-footed  where  no  appre- 
ciable difference  in  the  quantity  of  liquor  amnii, 
judging  from  previous  labors,  could  be  ascertained  ; 
and  we  have  recently  seen  a  case  of  double  equino- 
varus  in  a  twin,  the  other  child  showing  no  deform- 
ity whatsoever.  Billroth  states  as  follows  :  "  The 
typical  form  of  this  congenital  deformity  appears  to 
indicate  that  it  depends  on  a  disturbance  of  a  typical 
(symmetrical?)  development  of  the  lower  extremi- 
ties ;  for  if  festal  disease,  disturbance  of  an  irritative 


CLUB-FOOT:   TALIPES.  33 

nature,  or  abnormal  pressure  in  the  uterus  were  at 
fault,  cases  would  probably  differ."  He  also  quotes 
Eschricht  as  showing  that  at  the  commencement  of 
their  development  the  lower  extremities  lie  with 
their  backs  against  the  abdomen,  the  hollows  of 
their  knees  being  against  the  belly ;  so  during  the 
earlier  months  the  legs  must  rotate  on  their  axes, 
and  the  toes  which  pointed  backward  must  point  in 
the  opposite  direction.  If  the  embryonic  extremities 
lie  so  close  as  to  appear  united  under  a  common 
skin,  or  be  really  united,  the  above-mentioned  rota- 
tion of  the  limbs  cannot  take  place,  and  in  this 
deformity  (siren)  the  feet  are  turned  directly  back- 
ward. This  rotation  on  the  axis,  which  was  arrested 
in  the  above  case,  does  not  take  place  fully  in  club- 
foot, the  rotation  in  the  foot  is  not  fully  accomplished. 
Billroth  states  further,  that  according  to  this,  con- 
genital club-foot  would  come  among  the  cases  of 
obstructed  development;  about  its  cause  he  con- 
cludes we  know  as  little  as  we  do  of  other  deformi- 
ties of  the  same  class. 

H.  "W.  Berg,  of  New  York,  in  a  very  original 
article,  gives  failure  of  rotation  as  the  cause  of  con- 
genital equino-varus.  He  has  studied  the  subject 
from  specimens  seen  at  the  New  York  Hospital  and 
Wood's  Museum  of  Bellevue  Hospital,  and  describes 
the  changes  in  the  position  of  the  lower  extremities 
at  different  periods  of  foetal  life.  He  shows  that  in 
early  life  the  whole  leg  is  rotated  outward,  and  this 
outward  rotation  is  accompanied  by  an  exaggerated 
varus,  and  still  later,  an  equino-varus.  This  dimin- 
ishes as  the  rotation  to  the  normal  position  pro- 

3 


34  MEMOIR  OF  A.  S.  ROBERTS. 

gresses,  but  he  states  that  even  when  the  rotation 
of  the  leg  has  been  entirely  completed  some  of  the 
varus  still  remains,  and  calls  attention  to  the  very 
slight  varus  of  the  new-born.  In  addition  he  states 
that  equinus  is  often  seen  in  foetuses  of  two,  three, 
and  four  months.  This  he  does  not  always  find, 
and  it  disappears  in  the  course  of  the  normal  growth 
of  the  foot.  He  concludes  that  in  the  early  stage 
of  foetal  life  varus  or  equino-varus  is  physiological. 
He  does  not  think  pressure  necessary  to  the  produc- 
tion of  the  deformity,  its  cause  consisting,  in  his 
opinion,  of  a  non-  or  retarded  rotation  inward  of  the 
lower  extremity.  We  consider  this  theory  of  non- 
or  retarded  rotation  as  of  such  importance  from  an 
etiological  stand-point  that  we  quote  his  account  of 
its  mechanism  in  full.  He  says  :  "As  soon  as  the 
joints  are  formed  we  find  the  thigh  rotated  outward 
as  far  as  possible,  and  flexed  upon  the  body.  The 
leg  is  flexed  upon  the  thigh,  but  not  completely,  for 
this  is  prevented  by  the  extreme  outward  rotation 
of  the  thigh,  which  brings  the  inner  border  of  the 
leg  in  apposition  with  the  abdomen  of  the  child. 
We  have,  then,  the  inner  border  of  the  thigh  and 
the  tibial  border  of  the  leg  pressed  against  the  abdo- 
men of  the  foetus,  the  legs  crossing  each  other  a 
little  below  their  middle.  All  of  the  intra-uterine 
pressure,  therefore,  is  thus  brought  to  bear  directly 
upon  the  outer  border  of  the  thigh  and  leg,  corre- 
sponding to  the  fibular  border  of  the  leg,  and  also 
upon  the  dorsum  of  the  foot.  The  result  of  this  is 
that  the  foot  is  rotated  in  and  extended  (equino- 
varus)  until  the  sole  is  almost  on  a  line  with  the 


CLUB-FOOT :   TALIPES.  35 

inner  border  of  the  leg,  and  lies  against  the  body  of 
the  foetus,  while  the  dorsal  surface  of  the  foot  is  on 
a  convex-curved  line  with  the  outer  border  of  the 
leg,  to  adapt  itself  to  the  concave  wall  of  the  uterus. 
This,  I  believe,  is  a  stage  in  the  normal  develop- 
ment of  every  healthy  foetus  ;  and  were  the  extremi- 
ties to  remain  in  this  position,  all  children  would  be 
born  club-footed.  But  nature  provides  against  this 
by  the  inward  rotation  of  the  extremity,  which 
gradually  takes  place,  carrying  the  leg  away  from 
its  position  against  the  abdomen  of  the  foetus ;  and 
when  this  rotation  is  completed  we  find  the  extensor 
surface  of  the  thigh  flexed  and  in  relation  with  the 
body  of  the  child,  while  the  legs  are  flexed  upon 
the  thighs,  the  inner  or  tibial  borders  facing  each 
other.  Now  the  soles  of  the  feet  lie  against  the 
uterine  walls,  and  the  intra-uterine  pressure  is 
exerted  directly  upon  them.  This  produces  extreme 
flexion  of  the  foot  upon  the  leg,  together  with  an 
outward  rotation  of  the  foot ;  this  movement,  from 
the  constitution  of  the  ankle-joint,  accompanying 
extreme  flexion.  Thus  is  antagonized  the  varus  or 
equino- varus  existing  hitherto.  It  is  evident,  then, 
that  upon  the  completeness  of  the  internal  rotation 
or  torsion  which  takes  place  in  the  lower  extremity 
depends  the  rectification  of  the  early  varus  of  the 
foot.  Should  this  rotation  not  take  place  at  all,  or 
be  incomplete,  the  foot  will  continue  to  maintain  its 
early  relation  to  the  body  of  the  foetus  and  uterine 
walls,  and  the  child  will  be  born  more  or  less  club- 
footed.  If  this  be  so,  we  should  expect  to  find  in 
club-footed  children  that  the  extremities  are  rotated 


36  MEMOIR   OF  A.  S.  ROBERTS. 

outward.  And  this  we  do  find  upon  examination. 
In  all  of  the  cases  of  congenital  club-foot  (equino- 
varus)  which  I  have  seen  since  my  attention  has 
been  directed  to  this  subject,  I  have  found  that  the 
thigh  and  leg,  as  a  whole,  were  rotated  out,  and  the 
tibia  bent  at  its  lower  part,  so  that  the  feet  were 
approximated  to  each  other  in  addition  to  being  in 
the  clubbed  position.  All  this  is  seen  to  be  the 
result  of  non-rotation  of  the  leg."  In  1884,  two 
years  after  Dr.  Berg's  article  appeared,  Drs.  Parker 
and  Shattuck  published  a  pamphlet  on  "  The  Pathol- 
ogy and  Etiology  of  Congenital  Club-foot."  Their 
theory,  as  shown  in  their  argument,  is  as  follows : 
"  Our  argument  is  that  the  feet  of  the  foetus  occupy 
various  positions  during  the  period  of  intra-uterine 
life,  and  that  this  occurs  in  order  that  the  joint- 
surfaces,  the  muscles,  and  especially  the  ligaments, 
be  developed  so  as  to  allow  of  that  variety  of  posi- 
tions and  movements  which  are  afterward  to  be 
natural  to  the  foot ;  and  we  hold  that  when  any- 
thing (mechanically)  prevents  the  feet  from  assum- 
ing these  positions  at  the  proper  time,  or  maintains 
them  in  any  given  position  beyond  the  limit  of  time 
during  which  they  should  nominally  occupy  such 
position,  a  talipes  results.  The  variety  of  talipes 
will  depend  upon  the  date  of  its  production;  its 
severity  will  be  in  direct  ratio  to  the  mechanical 
violence  at  work.  If  the  inversion  of  the  foot, 
which  is  normal  during  the  earlier  months  of  foetal 
life,  be  maintained  beyond  the  normal  period  of  time, 
the  muscles  and  ligaments  will,  as  a  consequence, 
be  adaptively  short  on  one  aspect  of  the  limb,  and 


CLUB-FOOT:   TALIPES.  37 

too  long  on  the  other ;  a  normal  position  of  inver- 
sion will  finally  become  a  deformity.  Talipes  cal- 
caneus is,  we  believe,  produced  in  a  similar  manner; 
it  occurs,  however,  later  during  intra-uterine  life, 
when  a  flexed  position  of  the  foot  is  normal.  Being 
thus  less  fundamental  in  character,  it  is  also  less 
severe  as  a  deformity  than  varus." 

To  any  one  who  has  read  Berg's  monograph,  it 
will  appear  surprising  that  no  mention  of  it  is  made 
by  Parker  and  Shattuck.  This  is  all  the  more 
remarkable  in  that  Berg  had  fully  anticipated  not 
only  all  that  they  have  advanced,  but  had  followed 
these  data  and  observations  to  their  legitimate  logi- 
cal conclusions,  which  for  some  occult  reason  Parker 
and  Shattuck  have  avoided.  Had  they  cited  Berg's 
paper,  we  would  have  been  forced  to  the  conclusion 
that  the}7  had  attempted  to  prop  up  the  old  fanciful 
mechanical  theory  with  the  support  of  real  embryo- 
logical  data. 

We  have  endeavored  to  give  as  succinctly  as 
possible  the  different  theories  in  vogue  concerning 
the  etiology  of  congenital  club-foot.  They  may  be 
briefly  summarized  as  follows  : 

1.  The  theory  of  pathological  changes  affecting 
the  child  in  utero. 

2.  The  theory  of  mechanical  forces  acting  upon 
the  foetus  in  utero. 

3.  The  theory  of  heredity. 

4.  The  theory  of  arrest  of  development. 

5.  The  theory  of  non-  or  retarded  rotation. 

In  conclusion  we  would  state  that  it  certainly 
would    seem   most   reasonable,    with   our   present 


38  MEMOIR  OF  A.  S.  ROBERTS. 

knowledge  of  the  subject,  to  ascribe  the  causation 
of  congenital  club-foot  to  the  last-mentioned  theory, 
which  has  at  least  for  its  credit  the  fact  of  its  being 
demonstrable,  rather  than  to  those  which  for  their 
foundation  either  have  only  the  similarity  to  condi- 
tions produced  by  disease  after  birth,  or  are  entirely 
fanciful. 

Etiology  of  Acquired  Forms.  By  far  the  larger 
number  of  cases  of  club-foot  occur  as  acquired 
forms,  and  of  these  infantile  paralysis  (poliomyelitis 
anterior)  produces  the  greatest  number. 

Without  entering  into  a  lengthy  description  of 
this  disease,  which  can  be  found  in  any  of  the  text- 
books on  nervous  diseases,  and  also  in  another 
portion  of  this  work,  it  will  be  sufficient  to  state 
that  it  usually  occurs  during  the  period  of  dentition, 
beginning  with  fever  and  gastro-intestinal  disturb- 
ance, with  or  without  convulsions,  and  is  followed 
by  paralysis  more  or  less  severe.  This  paralysis  is 
followed  by  a  rapid  improvement  in  many  of  the 
muscles  involved,  those  of  the  upper  extremity  and 
trunk  usually  recovering  first,  while  those  of  the 
lower  extremity  remain  unilaterally  affected.  The 
paralysis  is  followed  by  atrophic  changes,  loss  of 
electro-muscular  contractility,  especially  to  the  fara- 
dic  current,  and  deformities,  of  which  club-foot  is 
the  most  frequent.  For  a  long  time  it  was  taught 
that  the  deformities  produced  by  infantile  paralysis 
were  due  solely  to  the  loss  of  power  in  one  set  of 
muscles  and  the  preponderating  action  of  their 
antagonists.  Thus,  in  consequence  of  this  loss  of 
balance  in  the  muscles  supporting  the  leg  and  foot, 


CLUB-FOOT:   TALIPES.  39 

were  produced  the  altered  relations  which  give  rise 
to  the  various  forms  of  acquired  club-foot.  Delpech 
taught  that  a  muscle  could  be  in  a  condition  of  per- 
manent or  tonic  spasm,  and  the  opponents  being 
paralyzed,  the  deformities  were  produced.  That 
this  view  is  faulty  has  been  proven  by  more  recent 
researches.  Hueter  first  called  attention  to  the  fact 
that,  owing  to  the  position  assumed  by  the  paralyzed 
limb,  its  weight  caused  contractions,  and  that  the 
so-called  antagonistic  contractions  were  not  at  all 
muscular  actions,  but  were  due  to  atrophy  and  lack 
of  growth.  Volkmann,  in  his  now  classical  lecture, 
has  gone  very  thoroughly  into  the  mechanism  of  the 
production  of  club-foot  due  to  infantile  paralysis. 
He  has  shown  that,  owing  to  the  superincumbent 
weight  of  the  body,  the  limbs  assume  positions 
which  gradually  become  permanent;  that  the  so- 
called  tonic  retraction  does  not  occur,  and  that  the 
shortening  of  the  muscles  is  due  not  to  contraction, 
but  to  growth  of  the  limb,  the  foot  remaining  in  its 
deformed  position. 

A  form  of  paralysis  usually  designated  as  spastic 
or  active — spastic  paralysis  (Erb),  paralysis  with 
rigid  muscles  (Adams),  and  tetanoid  paraplegia 
(Seguin) — is  also  productive,  of  club-foot.  In  this 
class  of  cases  a  more  general  dispensation  of  the 
consequences  of  the  lesion  seems  to  be  inflicted. 
The  patients  have  a  silly  or  semi-idiotic  look, 
although  their  intelligence  seems  rather  to  be  re- 
tarded than  obliterated.  They  frequently  squint, 
and  their  progression  is  peculiar  and  quite  charac- 
teristic.    They  walk  on  their  toes  with  their  knees 


40  MEMOIR  OF  A.  S.  ROBERTS. 

pressed  together,  and,  in  order  to  maintain  their 
equilibrium,  throw  one  limb  over  the  other,  walking 
as  it  were  cross-legged.  There  is  general  rigidity 
and  spasm  of  the  muscles,  all  the  reflexes  being 
greatly  exaggerated.  The  form  of  club-foot  in  these 
cases  is  usually  an  equinus,  and  the  contractions 
can,  for  the  time  being,  be  rectified  by  continuous 
pressure,  but  upon  its  cessation  the  feet  instantly 
assume  their  old  positions.  Its  pathology  would 
seem  to  indicate,  in  some  cases,  a  lack  of  develop- 
ment, in  others  a  lesion  of  some  portion  of  the 
motor  tract  of  the  brain,  followed  by  secondary 
changes  in  the  lateral  columns  of  the  cord.  Rup- 
precht,  of  Dresden,  has  studied  the  nature  and 
treatment  of  this  condition  very  thoroughly,  and 
has  shown  not  only  that  tenotomy  in  this  class  of 
cases  is  often  followed  by  improvement  in  the  posi- 
tion of  the  feet,  but  that  in  some  cases  there  was 
an  accompanying  improvement  in  the  mental  status 
of  the  patient.  For  further  information  on  this 
very  important  class  of  cases  the  reader  is  referred 
to  his  very  valuable  remarks  in  "Volkmann's  series 
of  clinical  lectures.  Many  authors  believe  that  this, 
or  a  similar  condition,  is  an  accompaniment  of 
various  spinal  diseases,  acute  compression,  syphilis, 
tumors,  and  caries. 

Among  other  conditions  due  to  disturbance  of 
the  nervous  system,  pseudo-hypertrophic  paralysis, 
post-hemiplegic  contractions,  and  neuromimesis  are 
productive  of  club-foot.  While  the  two  former 
classes  are  rare  as  causes  of  acquired  talipes,  the 
latter  or  neuromimetic  are  more  frequent,  and  have 


CLUB-FOOT:   TALIPES.  41 

of  late  years  attracted  considerable  attention.  Ex- 
amples of  these  very  interesting  cases  have  been 
cited  by  Paget,  Little,  Skey,  Shaffer,  Weir  Mitchell, 
Haward,  and  others.  They  undoubtedly  depend 
upon  the  neurotic  diathesis,  and  may,  by  their 
similarity  to  the  real  condition,  be  very  deceptive. 
Shaffer  has  devoted  considerable  space  to  this  class 
of  cases  in  his  work  on  "  The  Hysterical  Element  in 
Orthopaedic  Surgery,"  a  perusal  of  which  will  greatly 
aid  the  student  in  the  diagnosis  and  treatment. 

Cases  due  to  reflex  paralysis  have  been  reported 
by  Sayre  and  others,  who  claim  that  a  functional 
disturbance  of  the  nervous  system  can  cause  spasm 
of  certain  muscles,  which,  continuing  for  a  time, 
while  healthy  growth  is  going  on  in  their  opponents, 
so  disturbs  the  balance  of  power  as  to  produce  a 
permanent  deformity.  This  mode  of  the  production 
of  club-foot  has  recently  been  the  subject  of  much 
discussion,  many  authorities  altogether  disbelieving 
the  origin  of  the  deformity  by  this  means. 

The  paraplegia  accompanying  Pott's  disease  of 
the  spine  is  also  a  cause  of  acquired  club-foot.  It 
generally  occurs  as  an  equinus,  and  is  very  similar 
to  the  spastic  cases  previously  mentioned.  It  dis- 
appears as  the  paraplegia  improves. 

One  of  the  most  frequent  causes  of  acquired 
talipes  is  joint-disease  of  the  lower  extremity.  Here 
it  may  either  occur  symptomatically  or  follow  the 
disease  of  the  articulation.  Especially  is  this  true 
of  the  ankle-joint,  where,  at  different  periods  of  the 
inflammatory  trouble,  the  foot  assumes  an  equinus, 
varus,  or  valgus  position. 


42  MEMOIR  OF  A.  S.  ROBERTS. 

A  very  interesting  class  of  cases  are  those  due  to 
occupation.  In  these  cases,  occurring  principally 
in  bakers,  blacksmiths,  printers,  and  other  trades, 
the  principal  factors  are  the  weight  of  the  body 
and  long-continued  position,  and  it  is  in  this  class 
that  we  often  see  the  inflammatory  forms  of  club- 
foot. A  similar  class  of  cases  are  those  observed 
in  growing  boys  and  girls,  and  usually  occurring  at 
about  the  time  of  puberty.  Here  the  deformity, 
which  is  a  valgus,  is  probably  due  to  increased 
weight  and  rapid  growth  of  the  body,  without  a 
corresponding  growth  of  the  muscles  and  ligaments 
of  the  feet. 

Long-continued  decubitus,  as  in  the  continued 
fevers,  has  been  productive  of  club-foot,  generally 
an  equinus.  Volkmann  mentions  one  case  in  which, 
after  severe  typhoid  fever,  an  equinus  resulted,  and 
in  which  a  year  was  occupied  in  restoring  the  feet 
to  their  normal  position  by  active  orthopedic  treat- 
ment. 

Traumatisms,  resulting  in  deep  cicatrices  and 
burns  in  the  neighborhood  of  the  ankle-joint,  are 
also  causes  of  acquired  club-foot. 

History  aistd  Literature.  In  studying  the 
history  of  club-foot  it  has  been  thought  best  to 
divide  the  subject  into  three  periods :  a  Pre-conti- 
nental  period,  including  the  years  from  460  to  370 
B.C. ;  a  second,  the  Continental  and  Early  English, 
including  the  seventeenth  and  eighteenth  centuries; 
and  a  third,  or  Continental  and  English,  which  em- 
braces the  nineteenth  century  and  brings  us  down 
1  <  i  1  he  present  day.    To  render  the  study  more  com- 


CLUB-FOOT:   TALIPES.  43 

plete,  separate  notice  is  given  of  American  contri- 
butions, especially  valuable  for  their  originality  in 
the  mechanical  improvements  devised  for  the  relief 
of  this  deformity. 

I.  P  re-Continental  Period— B.C.  460-370.  The 
earliest  author  on  the  subject  of  club-foot  whose 
writings  are  preserved  or  accessible  is  Hippocrates. 
He  mentions  very  clearly  deformities  of  the  articu- 
lations, and  in  all  his  works  on  ancient  surgery, 
says  his  translator,  there  is  not  a  more  wonderful 
chapter  than  that  relating  to  club-foot,  on  which  he 
gives  most  valuable  information.  He  says:  "There 
is  more  than  one  variety  of  club-foot,  the  most  of 
them  not  being  complete  dislocations,  but  impair- 
ments connected  with  the  habitual  maintenance  of 
the  limb  in  a  certain  position."  He  says  further: 
"Most  cases  of  congenital  club-foot  are  remedial, 
unless  the  declination  be  very  great,  or  when  the 
affection  occurs  at  an  advanced  period  of  youth." 
For  early  treatment  he  relied  on  bandages,  for  the 
application  of  which  he  gave  very  particular  instruc- 
tions. He  says:  "  After  the  application  of  the  ban- 
dages, a  small  shoe  made  of  lead  is  to  be  bound  on 
externally,  having  the  same  shape  as  the  Chian 
slippers.  This  is  the  mode  of  cure,  and  it  neither 
requires  cutting,  burning,  nor  any  other  complex 
means."  This  might  imply  that  he  had  seen  or 
heard  of  other  means  of  curing  club-foot,  but  of 
them,  if  they  existed,  we  have  no  record. 

For  a  period  of  two  thousand  years  or  more  the 
subject  of  club-foot  was  apparently  completely 
ignored,  and  nothing  was  added  to  the  knowledge 


44  MEMOIR  OF  A.  S.  ROBERTS. 

collected  by  Hippocrates  and  handed  down  to  us 
by  Poly bius.  It  was  regarded  by  all  as  a  subject 
of  ill  omen,  and  those  unfortunately  afflicted  by  the 
deformity  as  being  especially  the  objects  of  divine 
wrath.  Superstition  forbade  men  from  even  men- 
tioning it,  much  less  of  devising  means  for  its  cure. 
Celsus,  whose  writings  cover  so  large  a  field,  does 
not  even  mention  it — a  fit  criterion  of  the  condition 
of  the  times. 

II.  Continental  and  Early  English  Period — Seven- 
teenth and  Eighteenth  Centuries.  It  was  not  until 
the  middle  of  the  seventeenth  century  that  the  ques- 
tion of  club-foot  again  came  into  notice. 

In  1641  Ambroise  Pare,  "  Les  GEuvres"  (Lyons), 
ascribed  club-foot  to  the  circumstance  that  the 
mother,  during  her  pregnancy,  had  been  sitting  too 
much  with  her  legs  crossed.  He  also  gives  a  model 
of  a  boot  for  the  treatment  of  the  deformity.  He 
was  followed  in  1643  by  Severinus,  who  wrote  of 
the  subject.  ("  De  Recondita  Abscessum  Natura," 
Francof.,  1643.) 

In  1658  Arcseus,  "  De  recta  curandorum  valuerum 
rational"  (Amstel.),  describes  a  process  for  the 
removal  of  the  distortion,  and  figures  an  apparatus 
and  a  boot  by  which  he  treated  deformities.  Fab- 
ricius,  in  1723,  "  Opera  Chirurgica  "  (Batavia),  pro- 
poses an  iron  boot  for  treating  deformities  of  the  feet. 

In  1741  Andry  first  used  the  term  orthopedy, 
and  published  a  work  on  the  subject  in  two  volumes, 
entitled  "  L'Orthopedie  "  (Paris).  It  is  evident  from 
his  remarks  that  he  does  not  limit  the  use  of  the 
term  to  club-foot,  as  some  authors  erroneously  sup- 


CLUB-FOOT:   TALIPES.  45 

pose,  but,  under  the  derivation  dpdbz,  straight,  and 
naedbz,  genitive  of  7tou<:,  child,  the  whole  subject  of 
the  retification  of  deformities  is  included. 

Du  Verney,  in  his  "  Traite  des  Maladies  des  Os  " 
(Paris,  1751),  contributed  a  very  important  chapter 
to  the  subject  of  club-foot.  He  recognized  the 
muscular  contraction  as  a  cause,  and  described  the 
distortion  as  due  to  the  influence  of  the  muscles 
and  ligaments.  He  writes  of  varus  and  valgus,  and 
ascribes  these  distortions  entirely  to  the  unequal 
tension  of  the  muscles  and  ligaments.  He  con- 
cluded that  those  muscles  which  are  extremely  tense 
draw  the  parts  toward  them,  while  their  antagonists 
yield,  being  relaxed. 

The  year  1784  brings  us  to  the  most  important 
era  in  the  history  of  club-foot  which  we  have  yet  to 
record,  and  from  this  date  a  marked  impetus  was 
given  to  the  proper  study  and  treatment  of  the  sub- 
ject. Thilenius,  a  physician  of  Frankfort,  proposed 
in  this  year  a  section  of  the  tendo  Achillis  for  a  case 
of  talipes  equinus,  and  the  operation,  an  open  one, 
was  performed  by  the  surgeon  Lorenz.  It  was  com- 
pletely successful,  and  the  same  operation  was  sub- 
sequently performed  by  Sartorius.  Thilenius  has 
written  under  the  title,  "  Medicinische  und  Chirur- 
gische  Bemerkungen  "  (Frankfort).  At  about  the 
same  time  "Venel,  called  by  some  the  "  Father  of 
Orthopedics,"  settled  in  Orbe,  Switzerland,  and 
founded  an  orthopedic  institution.  His  success  was 
such  that  Wanzel,  then  eleven  years  of  age,  was 
placed  under  his  treatment  with  double  club-foot. 
By  means  of  his  shoe  he  succeeded  in  curing  him 


46  MEMOIR  OF  A.  S.  ROBERTS. 

in  twenty-two  months.  This  induced  Bruckner,  of 
Gotha,  "  Ueber  ^Tatur,  Verfahren  und  Behandlung 
der  einwarts  gekriimmten  Fiisse"  (Gotha,  1796), 
and  Naumburg,  of  Erfurt,  "  Abhandlung  ueber  die 
Beeinkrummung  "  (  Leipsic,  1796),  to  use  and  perfect 
Venel's  method.  Wanzel  studiedmedicine  later,  and 
in  his  inaugural  thesis,  "  Dissertatio  Inauguralis 
medica  de  Talipedibus  Yaris"  (Tubingen,  1798), 
described  the  procedure  used  by  Venel.  Besides 
the  authors  already  quoted,  Ehrmann,  of  Germany, 
Tiphaisue  and  Yerdier,  of  France,  and  Jackson, 
Sheldrake,  and  Mark  Anthony  Petit,  of  England, 
contributed  to  the  literature  and  treatment  of  club- 
foot. 

Of  these  the  most  important  are  the  writings  of 
Thomas  Sheldrake,  of  London  (1798),  who  consid- 
ered the  contraction  of  the  ligaments  as  the  essential 
cause  of  club-foot.  He  aimed  his  treatment  essen- 
tially at  these  tissues.  His  own  words  are  as  follows : 
"  The  essential  operation  to  be  performed  in  curing 
a  club-foot  is  to  produce  such  an  extension  of  some 
of  the  ligaments  as,  if  it  happened  by  accident, 
would  constitute  a  sprain.  It  certainly  is  the  duty 
of  the  operator  so  to  conduct  this  operation  that 
none  of  the  consequences  which  would  have  taken 
place  from  an  accidental  operation  shall  ensue." 
Mark  Anthony  Petit,  of  England  (1799),  is  claimed 
to  have  had  the  first  example  of  tenotomy  on  record, 
and  to  have  been  the  first  surgeon  to  perform  it. 

This  closes  the  second  period  in  the  history  of 
club-foot,  and  while  we  can  see  the  gradual  progres- 
sion from  a  purely  empirical  idea,  both  of  the  nature 


CLUB-FOOT:   TALIPES.  47 

and  treatment  of  the  deformity,  to  a  broader  and 
more  comprehensive  conception  of  the  subject,  it 
will  be  admitted  that  as  yet  no  decided  scientific 
departures  had  been  made.  The  nearest  approach 
was  the  operation  of  Thilenius,  which  foreshadowed, 
as  it  were,  the  researches  which  were  to  follow,  and 
which  have  proved  of  such  invaluable  worth  to  the 
sufferers  from  club-foot. 

III.  Continental  and  English  Period — Nineteenth 
Century.  More  general  attention  seems  to  have 
been  directed  toward  the  study  and  treatment  of 
deformities  at  the  beginning  of  this  century,  and 
many  master-minds  in  different  countries  labored  to 
bring  the  subject  from  out  of  the  half  mystical,  half 
empirical  atmosphere  in  which  it  was  enshrouded  at 
the  close  of  the  last  century. 

This  period  was  opened  auspiciously  by  the 
writings  of  Ortlepp  in  Germany,  whose  work,  "  De 
Talipedibus,"  etc.  (Jena,  1800),  contains  many  ex- 
cellent suggestions ;  and  of  Bailly,  in  France,  who 
wrote  under  the  title  "Du  traitement  et  de  la  cura- 
bilite  du  pied-bot  invetere  "  (Lyons,  1802). 

They  were  followed  in  1803  by  Scarpa,  of  Pavia, 
who  in  his  work  on  club-foot,  "  Memoria  chirurgica 
sui  piedi  torti  congeniti  dei  fanciulli,  e  sulla  maniera 
di  corregere  questa  deformita  "  (Pavia,  1803),  main- 
tained the  opinion  entertained  by  Hippocrates,  that 
the  tarsal  bones  are  not  dislocated,  but  twisted  on 
their  axes,  and  only  partially  separated  from  their 
mutual  contact.  He  contended  that  the  primary 
disturbance  is  in  the  osseous  system,  and  that,  con- 
sequent on  this  displacement,  the  muscles  are  elon- 


48  MEMOIR  OF  A.  S.  ROBERTS. 

gated  or  retracted,  according  to  their  position.  He 
proved  by  dissection  the  inaccuracy  of  the  supposed 
cause  of  club-foot  residing  in  arrest  of  development 
or  malformation.  He  designed  an  apparatus,  uni- 
versally known  as  "Scarpa's  shoe,"  for  the  mechan- 
ical treatment  of  club-foot,  the  essential  principles 
of  which  are  retained  to  the  present  day,  and  on 
which  most  of  the  apparatus  used  at  present  are 
constructed.  Jorg,  of  Leipsic,  wrote  on  club-foot 
under  the  title,  "  Ueber  Klumpfusse  und  eine  leichte 
und  zweckmassige  Heilart "  (1803). 

On  the  10th  of  May,  1806,  Sartorius  repeated  the 
operation  of  Thilenius.  The  operation,  by  open 
wound  and  "  brisement  force  "  combined,  ended  in 
anchylosis.  In  1809  Michaelis,  of  Marburg,  wrote 
a  treatise  "  Ueber  die  Schwachung  der  Sehnen,"  etc. 
He  contended  that  in  almost  every  case  of  club-foot 
the  tendo  Achillis  is  too  short.  He  operated  upon 
several  cases  of  talipes  equinus  by  partial  division 
and  rupture  of  the  tendo  Achillis.  He  reports  that 
after  the  operation  he  at  once  brought  the  feet  in 
their  natural  position.  He  seems  to  have  operated 
very  frequently.  In  less  than  one  year  he  had  per- 
formed eight  operations  of  tenotomy:  three  for 
equinus,  one  for  varus,  three  for  contracted  knees, 
and  one  for  contracted  fingers. 

Artopoeus,  in  1810,  "  Sur  la  torsion  congenitale 
des  pieds  des  enfans,"  and  Goepel,  in  1811,  "  De 
Talipedibus  varis  ac  valgis,  corumque  cura,"  were 
also  important  contributors. 

In  1816  Delpech,  of  Montpellier,  executed  the 
fourth  operation  of  tenotomy  on  record.     He  vir- 


CLUB-FOOT:    TALIPES.  49 

tually  did  a  subcutaneous  operation,  inasmuch  as 
he  made  a  small  opening  through  the  skin  and 
remote  from  the  tendon.  He  laid  down  the  fol- 
lowing important  rules  for  the  performance  of  the 
operation : 

1.  The  tendon  was  not  to  be  exposed.  The  knife 
was  to  be  entered  at  a  distance  from  the  tendon, 
and  not  through  an  incision  in  the  skin  parallel  to  it. 

2.  After  section  the  divided  ends  of  the  tendon 
were  to  be  brought  together,  until  reunion. 

3.  Gradual  and  careful  extension  was  to  be  made 
before  complete  union. 

4.  Complete  extension  being  made,  the  limb  was 
to  be  fixed  in  this  position,  and  kept  there  until 
union  was  perfect. 

From  Delpech's  work,  "  Chirurgie  Clinique  de 
Montpellier "  (Paris,  1816),  and  "  De  l'Orthomor- 
phie  "  (1828),  it  does  not  appear  that  he  again  per- 
formed tenotomy. 

In  1817  D'lvernois  wrote  an  essay  on  club-foot 
entitled  "  Essai  sur  la  torsion  des  pieds  et  sur  le 
meilleur  moyen  de  les  guerir." 

He  was  followed  in  1820  by  Palletta,  who  at- 
tempted to  prove  that  the  primary  cause  of  the 
deformity  consisted  in  a  deficiency,  complete  or 
partial,  of  the  internal  malleolus  ("  Exercitationes 
pathological.,"  Paris,  1820). 

In  1823  Rudolphi,  in  his  "  Grundriss  der  Phy- 
siologie,"  added  much  valuable  information  to  the 
pathological  anatomy  of  club-foot.  He  believed  that 
club-hand  and  club-foot  did  not  depend  on  extrinsic 
causes,  but  frequently  occurred  in  young  children 

4 


50  MEMOIR  OF  A.  S.  ROBERTS. 

from  irritation  and  spasmodic  action.  He  also  first 
called  attention  to  the  fact  that  distortions  occur  in 
the  embryo  as  early  as  the  third  and  fourth  months 
of  foetal  life. 

From  1823  to  1831  many  important  contributions 
to  the  study  of  club-foot  were  made.  Of  these  the 
most  noticeable  were  those  of  Mellet,  "Considera- 
tions generales  sur  les  deviations  des  pieds  ; "  James 
Kennedy,  of  Glasgow,  "On  the  Management  of  Chil- 
dren in  Health  and  Disease"  (1825);  Stolz,  in  1826, 
"  Memoire  sur  une  variete  particuliere  du  pied-bot ;" 
Brims,  "  Dissertat.  inaug.  de  Talipede  varo"  (1827) ; 
Pech,  "  De  Talipedis  vari  et  valgi  causa  "  (1828)  ; 
Cruveilhier,  "  Anatomie  Pathologique "  (Paris, 
1829),  who  entertained  erroneous  ideas  of  club-foot 
and  hand,  thinking  that  a  cramped  position  in  utero 
was  the  sole  cause  of  these  congenital  distortions ; 
Tortuae,  in  1829,  "  Praktische  Beitriige  zur  Therapie 
der  Kinder-Krankheiten"  (Minister) ;  Buchetmann, 
1830,  "  Diss,  inaug.  Abhandlung  ueber  die  Platt- 
fuss"  (Erlangen);  and  Loeb  Davides  (1830). 

From  the  time  of  Delpech  until  1831  it  does  not 
seem,  judging  from  the  writers  just  quoted,  that  the 
operation  of  tenotomy  had  been  placed  on  such  a 
basis  that  its  performance  had  been  often  repeated, 
or  its  merits  further  investigated.  In  1821  Stro- 
meyer  not  only  resuscitated,  but  established  the 
operation  on  a  permanent  and  scientific  basis.  By 
his  discoveries  he  not  only  made  the  operation  pop- 
ular, but,  showing  the  impunity  with  which  muscles 
and  tendons  might  be  divided,  opened  the  field  for 
the  relief  of  deformities  which  before  had  baffled  the 


CLUB-FOOT:   TALIPES.  51 

surgeon,  and  which  had  condemned  the  sufferer  to 
a  lifelong  incapacity.  Like  all  new  departures, 
however,  his  disciples  undoubtedly  overdid  the 
operation,  and  its  applicability  was  oftentimes  lost 
in  the  desire  to  perform  it.  Thus  its  proper  appli- 
cation and  the  counter-indications  for  its  perform- 
ance have  only  been  the  result  of  experience ;  but 
to  Stromeyer  and  his  influence  is  undoubtedly  due 
the  success  attained  by  surgeons  at  the  present  day 
in  the  operative  treatment  of  club-foot.  He  wrote 
under  the  title  "  Beitrage  zur  operativen  Ortho- 
padik"  (Hanover,  1838).  In  1833  Stork  wrote 
very  learnedly  on  "  De  Talipedibus  varis."  He  was 
followed  in  1835  by  Vincent  Duval,  whose  writings, 
"  Traite  pratique  du  Pied,"  and  u  Des  Vices  Con- 
genitaux  de  Conformation  des  Articulations,"  con- 
tain many  useful  observations.  He  made  many 
important  statistical  deductions,  and  also  proposed 
a  classification  and  nomenclature,  which,  however, 
have  not  come  into  general  use.  He  is  also  said  to 
have  been  the  first  operator  upon  the  tendo  Achillis 
in  France.  In  the  same  year  Blance  wrote  his 
"  Diss,  inaug.  de  novo  ad  Talipedem  varem."  Ryan, 
of  London,  in  his  "  Practical  Treatment  of  Club- 
foot" (1835),  criticises  the  three  divisions  of  club- 
foot into  equinus,  varus,  and  valgus,  as  having 
the  merit  of  being  short,  but  the  want  of  being- 
exact.  Thus,  he  says,  it  is  necessary  that  the  form 
of  club-foot  called  equinus  should  be  carried  to  the 
greatest  degree  of  development  to  give  to  the  pa- 
tient's foot  the  appearance  of  a  horse-foot,  and  an 
examination  of  thirty  cases  seemed  to  justify  this 


52  MEMOIR  OF  A.  S.  ROBERTS. 

criticism.  In  regard  to  the  etiology,  he  considered 
general  or  partial  paralysis  dne  to  cerebro-spinal 
disease,  and  the  bad  position  of  the  child  in  utero 
as  the  two  great  causes ;  other  less  important  ones 
he  found  in  direct  injuries,  contusions,  inflammation 
of  the  knee  or  tibio-tarsal  joint,  and  nerve  lesions. 
He  did  not  think  tenotomy  a  justifiable  operation, 
unless  all  other  means  failed. 

In  1836  W.  J.  Little,  of  London,  who  was  a 
sufferer  from  acquired  club-foot,  and  who  vainly 
attempted  to  have  an  operation  performed  in  Eng- 
land, proceeded  to  Hanover,  where  he  was  operated 
on  by  Stromeyer  for  an  equino-varus.  In  July  of 
the  same  year  he  himself  nerformed  the  operation 
in  Hanover.  He  then  went  to  Berlin,  and  with 
Dieffenbach  treated  numerous  cases  of  distortion. 
On  February  20, 1837,  Little  is  soid  to  have  divided 
the  tendo  Achillis  for  the  first  time  in  England, 
although  the  honor  was  claimed  by  two  men  before 
him,  by  M.  A.  Petit,  in  1799,  and  by  Whipple,  of 
Plymouth,  in  May,  1836,  who  states  that  when  he 
performed  the  operation  he  was  not  aware  that  it 
had  been  performed  on  the  Continent,  and  that 
Brodie,  to  whom  he  wrote  on  the  subject,  discoun- 
tenanced i ;,  but  that  Liston  sanctioned  the  opera- 
tion. To  Little,  however,  is  undoubtedly  due  the 
credit  of  popularizing  the  operation  in  England, 
and  to  his  influence  the  advancement  of  orthopedic 
surgery  is  largely  owing.  He  is  said  to  have  been 
the  first  to  use  the  term  "Talipes"  (Talus,  an  ankle, 
and  pes,  a  foot)  in  its  generic  signification,  although 
the  term  had  previously  been  used  by  writers  in  a 


CLUB-FOOT:   TALIPES.  53 

more  limited  sense.  He  saw  and  described  talipes 
calcaneus,  and  made  extensive  researches  into  the 
pathological  anatomy  of  club-foot,  considering  the 
muscles  as  the  parts  primarily  attacked.  In  regard 
to  tenotomy,  Little  says  :  "  The  most  favorable  time 
for  division  of  tendons  is  a  few  months  before  the 
child  may  be  expected  to  walk — about  the  age  of 
six  or  eight  months,  until  which  time  mechanical 
apparatus  should  be  used."  Little  wrote  his  "Trea- 
tise on  the  Nature  of  Club-foot "  in  1839,  and  "  On 
the  Nature  and  Treatment  of  the  Deformities  of  the 
Human  Frame  "  in  1853,  both  being  standard  works 
on  the  subject  to  this  day.  Kennedy,  of  Dublin, 
"  Obcervations  on  Cerebral  and  Spinal  Apoplexy, 
Paralysis,  and  Convulsions  of  New-born  Children," 
and  Martin,  "  Premier  Memoire  sur  le  Pied-bot," 
were  also  among  the  most  prominent  publications 
of  this  year ;  the  latter  ascribing  congenital  club- 
foot to  deficiency  of  the  liquor  amnii.  In  1837 
Sewald  (Berlin)  wrote  his  celebrated  thesis,  "  Diss. 
inaug.  de  Talipedibus,"  as  also  Lode,  "  Diss,  inaug. 
de  Talipedibus  varis  et  curvatura  Manus,"  etc.  In 
the  same  year  Pivain  wrote  his  essay  entitled,  "  Sur 
la  Section  du  Tendon  d'Achille,"  etc.  Attention 
was  also  called  to  the  subject  of  flat-foot,  by  Never- 
mann,  in  an  article  entitled  "  Ueber  den  Platfuss 
und  seine  Heilung."  In  1838  Kness  studied  the 
subject  carefully,  and  embodied  his  researches  in  an 
article,  "  De  Talipede  Varis,"  and  Wigel  in  the 
same  year  gave  a  resume  of  the  operative  treatment 
under  the  title  "  De  Operatione  Vari." 

In  1839  Velpeau,  of  Paris,  gave  much  attention 


54  MEMOIR  OF  A.  S.  ROBERTS. 

to  the  subject  of  club-foot,  and  wrote  on  the  sub- 
ject in  his  "  Nouveaux  Elements  de  Medecine  Ope- 
ratoire."  He  advised,  after  division  of  the  tendons, 
the  reduction  of  the  foot,  by  a  powerful  instrument, 
to  its  normal  position,  and  also  its  immediate  fixa- 
tion. He  called  attention  to  the  importance  of  the 
posterior  tibial  tendon,  and  describes  the  operation 
for  its  division,  its  dangers,  and  advantages. 

In  the  same  year  Krauss  wrote  on  "  The  Cure  of 
Club-foot,  Bent-knee,  Long  JSTeck,  Spinal  and  other 
Deformities,  with  Cases."  He  was  an  ardent  advo- 
cate of  tenotomy,  although  he  says  "  in  congenital 
club-foot,  if  advice  be  early  sought,  a  cure  may  be 
attempted  by  mechanical  means  alone,  but  never- 
theless, in  children  one  and  two  years  old  tenotomy 
is  better."  Hauser  "  on  Talipes  Varus  "  (Tunice), 
and  De  Russdorff,  "  De  Talipedibus,"  were  also  im- 
portant contributors  in  this  year.  Between  the  years 
1834  and  1840  we  find  tenotomy  practised,  and  its 
effects  upon  the  tendons  very  carefully  studied,  by 
such  men  as  Bouvier,  of  Paris,  Pauli,  Von  Amnion, 
Phillips,  Held,  Scoutetten,  of  Strasbourg,  Bonnet, 
of  Lyons,  Jules  Guerin,  of  Paris,  Dieffenbach,  of 
Berlin,  and  Pirogoff.  The  researches  of  Bonnet  are 
described  in  his  "Memoire  sur  la  section  du  tendon 
d' Achillo  dans  le  traitement  des  Pieds-bots;"  Pauli 
in  his  essay  "  Ueber  de  Klumpfuss  und  dessen 
Ileilung."  The  other  contributors  are :  Von  Am- 
nion, who  studied  the  effect  of  tenotomy  very  care- 
fully in  his  "  De  Plrysiologia  Tenotome ;"  Phillips, 
k%  Mibcutaneous  Tenotomy  in  Club-foot;"  Held, 
;'  Sur  le  Pied-bot;"  Scoutetten  (Strasbourg),  "Mem- 


CLUB-FOOT:   TALIPES.  55 

oir  on  the  Radical  Cure  of  Club-foot;"  Bonnet 
(Lyons),  "  Trait e*  des  Sections  Tendineuses,"  etc.; 
Jules  Guerin  (Paris),  "  Memoir  upon  the  Etiology 
of  Congenital  Club-foot;"  Dieffenbach  (Berlin), 
"Ueber  die  Durchschneidnng,"  and  Pirogoff, 
"  Ueber  die  Durchschneidung  der  Achilles." 

From  the  experiments  of  Bonnet,  he  was  led  to 
regard  the  cause  of  congenital  club-foot  as  residing 
in  the  tibial  nerve.  Pirogoff  described  two  modes 
of  performing  tenotomy : 

1.  Introducing  the  knife  between  the  skin  and 
tendon  and  cutting  inwardly.  2.  Introducing  the 
knife  between  the  bone  and  tendon  and  cutting  out- 
wardly. The  latter  operation  was  always  followed 
by  effusion  of  blood  into  the  sheath  of  the  tendon. 

Jules  Guerin  believed  tenotomy  was  not  necessary 
for  very  young  children,  and  that  bandages  were 
alone  sufficient  for  the  reduction  of  varus.  He  is 
among  the  first  to  have  used  plaster  of  Paris  in  the 
treatment  of  club-foot. 

Scoutetten's  mode  of  treatment  was  by  tenotomy 
and  an  apparatus  combining  fixation  with  flexion 
and  extension. 

In  1840  Coates  published  his  "Practical  Observa- 
tions on  the  Nature  and  Treatment  of  Talipes  or 
Club-foot,"  etc.  (London),  and  Heine,  of  Stuttgart, 
his  "  Beobachtungen  ueber  Lahmungszustande  der 
Extremitaten  und  deren  Behandlung,"  a  very  scien- 
tific work  on  the  production  of  the  deformities. 

In  1841  Vallin,  in  his  "Abridged  Treatise  on 
Club-foot"  (Nantes),  gave  it  as  his  opinion  that 
muscular  contraction   played   the  most  important 


56  MEMOIR  OF  A.  S.  ROBERTS. 

part  in  the  production  of  club-foot.  He  say s :  "  The 
circumstance  which  has  the  most  influence  upon  the 
efficacy  of  the  treatment  of  club-foot  by  apparatus 
is  the  possibility  of  acting  directing  upon  the  dis- 
placed bones,  and  upon  the  causes  which  produced 
their  displacements." 

In  the  same  year  Kennedy,  of  Dublin,  wrote  his 
"  Observations  on  Paralytic  Affections  met  with  in 
Children,"  which  contains  many  important  notes  on 
club-foot.  In  1842  Dunbar  writes  of  the  subject  in 
his  "Notes  on  the  Surgery  of  Deformities,  Club- 
foot." In  this  year  Lizars  (Edinburgh),  "  Opera- 
tion for  Cure  of  Club-foot,"  says  that  "  the  child 
must  be  old  enough  to  walk  before  the  operation  of 
tenotomy  is  performed.  Two  or  three  years  of  age 
is  the  earliest  time  at  which  tenotomy  should  be 
practised."  After  tenotomy,  he  advised  a  bandage 
from  the  instep  to  the  toes,  and  over  this  a  paste- 
board splint.  In  1843  Rilliet  and  Barthez  write 
learnedly  on  the  subject  in  their  "Traite  clinique  et 
pratique  des  Maladies  des  Enfants,"  and  Petitjean 
wrote  his  work  "  Du  Pied-bot."  In  1845  Chelius, 
in  his  "System  of  Surgery"  (London),  devotes 
some  space  to  the  subject.  In  1846  the  most 
important  work  was  that  of  Tamplin,  whose  "  Lec- 
tures on  the  Nature  and  Treatment  of  Deformities  " 
(London)  was  long  one  of  the  standard  works  on 
the  subject,  and  may  be  advantageously  consulted 
by  the  student  at  the  present  day.  He  devised 
many  new  modes  of  treatment,  and  his  statistics  as 
to  relative  frequency  are  very  valuable.  Meyer, 
"  De  Talipede  varis,"  etc.,  and  Muller,  "  De  Valgi 


CLUB-FOOT:   TALIPES.  57 

pedis  aetiologia  quaedam,"  also  wrote  in  the  same 
year.  Morrison,  in  1847,  "  Snr  les  Pieds-bots,"  and 
Berstedt,  "  De  Pedum  Deformitatibus"  (1848),  are 
valuable  contributions.  In  1849  Lonsdale  wrote 
his  celebrated  work  "  On  Some  of  the  More  Practical 
Points  Connected  with  the  Treatment  of  Deformi- 
ties "  (London). 

In  1850  Degaille  wrote  on  the  etiology  and  treat- 
ment under  the  title  "  De  l'Etiologie  et  du  Traite- 
ment  du  Pied-bot."  He  was  followed,  in  1852,  by 
Bishop,  of  London,  whose  work,  "  Researches  into 
the  Pathology  and  Treatment  of  Deformities  in  the 
Human  Body,"  is  a  careful  summary  of  the  subject. 
At  about  this  time  much  attention  was  given  to 
the  repair  of  tendons  after  tenotomy,  and,  although 
investigations  concerning  this  process  had  been 
made  by  Von  Amnion,  Guerin,  Pirogotf,  Koerner  and 
others,  it  was  left  for  Gerstaecker  (1851),  "  Diss. 
Histol.  de  Regeneratione  Tendinum;"  Thierfelder 
(1852),  "Trans.  Path.  Society"  (London,  vol.  vi., 
1855) ;  J.  H.  Boner  (1854),  "  Die  Regeneration  der 
Sehnen,"  etc.,  who  performed  many  experiments  on 
rabbits,  but  especially  Paget,  "  Lectures  on  Surgical 
Pathology "  (London,  1853),  who  has  detailed 
minutely  the  microscopic  changes  through  all  the 
stages  of  the  reparative  process,  and  to  whom  we 
are  largely  indebted  for  our  knowledge  of  the  sub- 
ject, to  show  the  exact  mode  in  which  the  required 
elongation  of  muscles  is  obtained  in  order  to  cure 
the  deformities  for  which  the  operation  is  performed. 
Adams,  in  1855,  also  performed  experiments  upon 
rabbits  in  which  the  tendo  Achillis  had  been  divided 


58  MEMOIR  OF  A.  S.  ROBERTS. 

subcutaneously,  and  has  written  "  On  the  Nature 
and  Treatment  of  Club-foot"  (London,  1856),  and 
a  "  Treatise  on  the  Reparative  Process  in  Human 
Tendons "  (London,  I860),  in  which  he  gives  a 
resume  of  the  published  descriptions  of  experiments 
on  animals,  as  well  as  post-mortem  examinations  in 
the  human  subject.  His  work  "  On  Club-foot :  its 
Causes,  Pathology,  and  Treatment,"  is  the  most 
exhaustive  on  the  subject,  and  received  the  Jack- 
sonian  prize  for  1864.  It  has  passed  through 
several  editions. 

Brodhurst,  of  London,  has  contributed  largely  to 
the  subject  of  club-foot,  the  most  important  of  his 
writings  being  "  On  the  Nature  and  Treatment  of 
Club-foot"  (London,  1856)  and  his  work  "  Ortho- 
pedic Surgery."  He  was  a  decided  advocate  of 
tenotomy,  and  employed  it  to  the  exclusion  of  all 
other  means  of  treatment,  considering  it  better,  even 
in  the  most  simple  cases,  to  divide  the  tendons.  He 
made  numerous  experiments  upon  the  reparative 
process  following  the  section  of  tendons,  the  results 
of  which  were  embodied  in  a  communication  to  the 
Royal  Society  (November,  1859),  entitled  "  On  the 
Repair  of  Tendons  after  their  Subcutaneous  Divi- 
sion." From  1853  to  1863  many  valuable  papers 
upon  the  subject  of  club-foot  appeared.  Among 
the  most  noteworthy  were  those  of  Todd,  "  Clinical 
Lecture  on  Paralysis "  (London,  1854) ;  Bouchut, 
"  A  Practical  Treatise  on  the  Diseases  of  Children  " 
(1855);  Beckel,  "  De  Pede  Yaro"  (1856);  Vetter, 
"De  cyllopodia  cum  descript.  casus  pedi  vari;" 
Ksau,    "Beitrage     zur     Lehre    von     Plattfuss ; " 


CLUB-FOOT:   TALIPES.  59 

Quicken,  "  De  Talipedibus"  (1859);  Ebner,  "Die 
Contracture!!  der  Fusswurzel  und  ihre  Behandlung" 
(1860) .  In  1863  Barwell,  "  Cure  of  Club-foot  with- 
out Cutting  Tendons,"  rendered  himself  famous  by 
offering  objections  to,  and  strongly  opposing,  the 
practice  of  tenotomy,  which  after  nearly  a  century 
of  use  had,  of  course,  become  very  popular,  and 
was  supported  by  all  the  great  surgeons.  His 
treatment  was  directed  to  the  restoration  of  the  lost 
equilibrium  in  the  opposing  sets  of  muscles  ;  to  sub- 
stituting a  force  for  the  paralyzed  muscles,  to  be 
applied  as  nearly  as  possible  in  the  direction  and 
position  of  the  paralyzed  muscles ;  to  treating  the 
foot,  not  as  a  whole,  but  as  a  compound  of  many 
bones ;  and  to  allowing  the  weakened  muscles  to 
regain  their  power  by  what  might  be  called  passive 
motion.  This  he  endeavored  to  accomplish  by  the 
use  of  india-rubber  bands,  also  called  "  artificial 
muscles."  In  his  objections  to  tenotomy  he  argues 
that  the  contraction  is  the  result  of  paralysis  in  the 
opposing  muscles.  When  the  tendon  is  cut,  all 
opposition  to  such  contraction  is  annihilated,  and 
the  muscle  itself  contracts  and  the  calf  shortens. 
Tonic  contraction  of  the  muscle,  however,  still  con- 
tinues, and  the  cicatricial  contraction  will  reproduce 
the  same  deformity  when  the  apparatus  is  removed. 
Non-union  occasionally  takes  place.  Weber,  "  Ueber 
die  Anwendung  permanenter  Extension  durch  elas- 
tische  Strange  bei  pes  valgus"  (1863),  also  advo- 
cated elastic  force.  Adams,  in  1866,  writes  that 
Heather  Bigg  had  used  the  same  plan  several  years 
prior  to  Barwell.    Many  works  appeared  during  the 


60  MEMOIR  OF  A.  S.  ROBERTS. 

latter  end  of  this  period,  and  the  literature  of  club- 
foot is  now  very  voluminous.  Stoess,  in  1866,  wrote 
on  "Du  Traitement  du  Varus;"  Richter,  in  1867, 
on  "  De  Talipedibus  Varis  ;"  Mezger,  in  1868,  "  De 
Behandlung  van  di  Stortistic  Pedis  mit  Fricties  ; " 
Hirschfield,  in  1869,  "  Ueber  die  Behandlung  der 
Klumpfusse ; "  Francellon,  in  the  same  year,  "De 
TEtiologie  du  Pied-bot  Congenital."  In  1870  Nie- 
den,  "  Ueber  die  Entstehungsweise  und  Ursache  des 
angeborenen  Klumpfusses ;"  Volkmann,  "Ueber 
Kinderliihmung  und  paralytische  Contracturen " 
(Klinisehe  Vortrage,  ~No.  1),  and  Marx,  "  Ueber 
Pes  Varus."  In  1871  James  Hardie,  "  On  the  Pa- 
thology of  Club-foot  and  other  Allied  Affections" 
(London);  A.  Luecke,  "  Ueber  den  angeborenen 
Klumpfuss"  (Volkmann's  Klinisehe  Vortrage),  and 
Brodhurst,  "  Deformities  of  the  Human  Body " 
(London).  In  1872  Keverchon,  "  Sur  le  Pied-bot," 
and  "  Du  Traitement  des  Pieds-bots  par  le  Massage 
force."  In  .1877  Chalot,  "  Du  Pied  Plat  et  du  Pied 
Creu  Valgus  Accidentels."  In  1878  Kocher,  "  Zur 
Etiologie  und  Therapie  des  Pes  Varus  Congenitus" 
("  Deuts.  Zeit.  f.  Chrr.,"  Bd.  ix.),  and  Bornemann, 
"Zur  Therapie  des  Pes  Varus  Congenitus."  In 
,1880  Van  Hees,  "  Ueber  Pes  Equino-varus."  In 
1881  Kuprecht,  "  Angeborene  spastische  Glieder- 
starre  und  spaslische  Contracturen"  ("Klinisehe 
Vortrage") ;  Dieffenbach,  "  Ueber  Pes  Varus  und 
seine  Behandlung;"  Koutier,  "Du  Pied-bot  Acci- 
dentel,"  and  Ulcoq,  "  Du  Pied-bot  Consecutif  a,  la 
Paralysie  infantile  et  de  son  Traitement."  In  1882 
Pascaud,  "Of  Certain  Orthopedic  .Vpparatus  em- 


CLUB-FOOT:   TALIPES.  61 

ployed  in  the  Treatment  of  Club-foot" ;  Noble  Smith, 
"  Surgery  of  Deformities."  In  1883  Schwartz, 
"  Des  Differentes  Especes  de  Pied-bot,  et  de  leur 
Traitement."  In  1884  Parker  and  Shattuck,  "  The 
Pathology  and  Etiology  of  Congenital  Club-foot." 
In  1385  Reeves,  "Practical  Orthopaedics"  (section, 
Talipes  or  Club-foot). 

This  brings  us  to  the  close  of  the  third  period, 
and  down  to  the  present  day.  We  have  endeavored 
to  give  the  more  important  works  which  mark  the 
history  of  the  subject,  and  to  note  those  particularly 
whose  views  characterized  the  development  of  new 
theories  as  to  etiology  and  treatment. 

American  Contributors — Nineteenth  Century.  In 
1835,  four  years  after  Stromeyer  performed  his  first 
operation,  Dr.  James  H.  Dickson,  of  North  Caro- 
lina, is  reported  to  have  performed  the  operation  of 
subcutaneous  tenotomy  for  the  first  time  in  America. 

In  1839  Mutter,  of  Philadelphia,  delivered  "  A 
Lecture  on  Club-foot,"  in  which  he  advocated  well- 
regulated  and  continued  extension,  which  he  believed 
was  the  only  thing  necessary,  especially  for  the 
young  and  feeble.  In  other  cases  he  advised  ten- 
otomy and  the  proper  fixation  and  retention  of  the 
foot,  followed  by  apparatus.  He  believed  the  imme- 
diate or  proximate  cause  of  congenital  club-foot  was 
a  contraction  of  the  tendo  Achillis.  Accidental 
causes  of  acquired  club-foot  he  ascribed  to  contu- 
sions, sprains  and  luxations,  fractures,  preternatural 
laxity  of  the  ligaments,  and  partial  paralysis  of  the 
lower  extremities. 

In  1840  Detmold,  of  New  York,  in  his  "Essay 


62  MEMOIR  OF  A.  S.  ROBERTS. 

on  Club-foot,"  states  that  the  only  remedy  to  be 
relied  upon  in  the  cure  of  club-foot  consisted  in  the 
extension  of  the  contracted  muscles,  gradually  in- 
creased and  continued  until  one  set  of  muscles  lose 
the  inclination  to  spasmodic  contraction,  and  their 
antagonists  regain  their  activity.  In  regard  to  the 
causes  of  club-foot,  he  believed  the  first  and  most 
frequent  cause  to  be  "  irregular  muscular  action," 
the  stronger  muscles  contracting,  and  the  weaker 
ones  yielding ;  second  cause,  paralysis  ;  third  cause, 
a  local  stimulus  or  irritation,  setting  up  contraction. 
He  thought  that  in  cases  due  to  the  first  cause,  the 
prognosis  was  gravest,  and  most  favorable  when  the 
condition  was  due  to  prolonged  contraction  from  a 
local  stimulus.  A  pupil  of  Stromeyer,  and  having 
had  the  opportunity  of  seeing  him  operate,  he  was 
an  ardent  advocate  of  tenotomy,  and  to  him  and 
Mutter  is  due  the  credit  of  making  the  operation  of 
subcutaneous  tenotomy  popular  in  this  country. 
Although  many  articles  in  different  journals  ap- 
peared upon  the  subject  of  club-foot,  and  many 
plans  of  treatment  showing  much  originality  were 
devised,  it  was  not  until  1866  that  a  methodical 
account  of  the  subject  was  given  by  Prince,  in  his 
"  OrthopaBdics  "  (Philadelphia).  He  also  gives  a 
\«iy  ingenious  plan  for  holding  the  foot,  for  the 
purpose  of  affixing  apparatus  for  the  removal  of  the 
deformity.  He  was  followed  in  1867  by  Davis,  who 
was  the  originator  and  promulgator  of  the  "  exten- 
sion "  theory,  and  to  whom  much  credit  is  due  for 
his  original  work  in  the  treatment  of  deformities. 
In    his  work,  "Conservative  Surgery,"  he  claims 


CLUB-FOOT:    TALIPES.  63 

that  he  had  practised  Barwell's  plan  many  years 
before  Barwell  adopted  it.  In  1868  Bauer's  "  Or- 
thopaedic Surgery  "  was  published.  It  is  undoubt- 
edly the  most  complete  and  scientific  work  upon  the 
subject  up  to  this  date,  and  its  chapter  on  Talipes 
is  a  very  comprehensive  and  exhaustive  one.  In 
1875  Say  re,  in  "A  Practical  Manual  of  the  Treat- 
ment of  Club-foot,"  shows  himself  a  decided  advo- 
cate of  "  Barwell's  artificial  muscles,"  although  he 
does  not  believe  in  this  method  to  the  exclusion  of 
other  means  of  mechanical  treatment  and  tenotomy. 

In  this  work  he  gives  many  excellent  practical 
suggestions  for  the  treatment  of  the  deformity,  and 
in  this,  as  well  as  other  departments  of  orthopedic 
surgery,  he  has  done  much  for  the  advancement  of 
the  subject. 

Shaffer,  of  N"ew  York,  has  devised  many  impor- 
tant improvements  in  mechanical  appliances  for 
the  cure  of  club-foot,  and  has  contributed  valuable 
articles  to  the  literature  of  the  subject.  The  most 
important  of  these  are :  "  Traction  in  the  Treatment 
of  Club-foot"  (1878) ;  "Hysterical  Joint-Affections" 
(1880),  in  which  he  reports  very  interesting  cases 
of  "hysterical  club-foot;"  and  "Non-deforming 
Club-foot "  (1885),  originating  in  this  last  contribu- 
tion a  new  class  of  cases,  previously  little  observed 
or  studied. 

Phelps,  of  Chateauguay,  advocated  and  practised 
division  of  the  tendo  Achillis,  and  then  of  all  struc- 
tures down  to  the  bones  opposite  Chopart's  joint. 
He  read  a  paper  on  the  subject  before  the  Interna- 
tional   Medical   Congress  at  Copenhagen,  entitled 


(54  MEMOIR  OF  A.  S.  ROBERTS. 

"  The  Treatment  of  Equino-varus  by  Open  In- 
cision." 

Hingston,  of  Montreal,  "  On  Certain  Forms  of 
Club-foot"  (1881),  reports  four  eases  of  severe 
equino-varus  treated  by  open  incision. 

Berg,  of  New  York,  has  written  a  very  original 
and  valuable  article  on  "  The  Etiology  of  Congenital 
Talipes  Equino-varus  "  (1882),  the  studies  of  the 
author  throwing  much  light  upon  this  very  vexed 
question  and  antedating  the  researches  of  Parker 
and  Shattuck,  of  London,  by  several  years.  Many 
other  names  might  be  added  to  the  foregoing  ones, 
most  conspicuously  those  of  Paneoast,  of  Phila- 
delphia; Hutchison,  of  Brooklyn;  Yale,  of  New 
York ;  Bradford,  of  Boston ;  all  of  whom  have 
added  either  to  the  treatment  or  the  literature  of 
club-foot. 

Varieties  Especially  Considered.  Under 
this  heading  will  be  included  a  short  account  of  the 
different  forms  of  club-foot  and  their  treatment,  as 
well  as  some  considerations  concerning  their  morbid 
anatomy,  pathology,  diagnosis,  and  prognosis. 

The  purely  primitive  types  of  club-foot  are  so 
rare,  either  as  congenital  or  acquired  deformities, 
that  authors  have,  under  the  titles  Varus,  Valgus, 
Equinus,  and  Calcaneus,  usuall}7  included  the  com- 
pound forms,  and  nearly  all  works  upon  the  subject 
have  described  the  changes  found  in  them  when 
referring  to  the  bones,  ligaments,  muscles,  etc.,  in- 
volved in  the  malformation.  This  has  led  to  much 
confusion  in  both  nomenclature  and  statistics.  It 
was  thought  necessary  to  call  attention  to  this  fact 


CLUB-FOOT:   TALIPES.  65 

before  proceeding  to  a  description  of  the  primitive 
types. 

Talipes  Yarns.  Synonyms :  Ger.,  Klumpfuss;  Fr., 
Pied-hot  varus.  The  simple  form  is  undoubtedly 
one  of  the  rarest  of  either  congenital  or  acquired  de- 
formities, it  being  generally  associated  with  equinus, 
and  almost  all  authors  when  writing  of  varus  de- 
scribe the  compound  form,  Talipes  Equino-varus. 
In  the  mildest  form  there  is  a  slight  inversion  of 
the  anterior  part  of  the  foot,  the  heel  not  being 
elevated.  In  a  true  case  of  varus,  therefore,  the 
deformity  would  take  place  at  the  transverse  tarsal 
joint,  the  deformity  being  on  a  lateral  plane.  The 
changes,  bony,  muscular,  and  ligamentous,  as  well 
as  the  treatment  of  the  simple  form,  will  be  best 
described  under  the  head  of  Talipes  Equino-varus. 

Talipes  Valgus.  Splay-foot,  Flat-foot.  Syno- 
nyms:  Ger.,  Plattfass  ;  Fr.,  Pied-hot  valgus.  This 
deformity  may  be  congenital  or  acquired,  the  latter 
form  being  very  frequent,  the  congenital  rare.  In 
the  congenital  form  there  are  e version  and  elevation 
of  the  outer  border  of  the  foot,  the  weight  of  the 
body  being  sustained  upon  its  inner  side.  With 
this  we  find  a  sinking  of  the  normal  convexity  of 
the  arch.  Here,  as  in  varus,  in  the  primitive  type, 
the  deformity  takes  place  on  a  lateral  plane,  and 
occurs  at  the  transverse  tarsal  joint. 

The  bones  are,  as  a  rule,  not  very  much  displaced,, 
the  principal  changes  taking  place  in  the  astragalus 
and  scaphoid  bones,  the  os  calcis  only  being  impli- 
cated when  there  is  a  co-existing  equinus.  The 
astragalus  is  generally  pushed  downward  and  for- 

5 


6Q 


MEMOIR  OF  A.  S.  ROBERTS. 


ward,  and  is  seen  as  a  prominence  upon  the  inner 
side  of  the  foot,  with  the  rotated  scaphoid  bone, 


Fig.  i. 


Acquired  talipes  valgus. 


CLUB-FOOT:   TALIPES.  67 

which  is  also  prominent.  The  enboid  bone  is  in- 
volved, being  slightly  rotated  outward,  and  the 
malleoli  have  a  lower  plane  than  normal.  The  liga- 
ments implicated  are  those  upon  the  plantar  surface 
and  inner  side,  the  calcaneo-scaphoid  ligament 
being  relaxed. 

The  muscles  principally  involved  are  the  peronei 
and  the  extensor  longus  digitorum,  the  tendo  Achillis 
only  participating  when  there  is  an  equino-valgus. 

Pes  Valgus  Acquisitus  (see  Fig.  1).  The  ac- 
quired form,  generally  known  as  splay-foot  or  flat- 
foot,  occurs  very  frequently,  and  if  all  the  cases 
were  grouped  under  the  common  title  of  Talipes 
Valgus,  would  undoubtedly  constitute  the  most 
frequent  form  of  club-foot.  A  reference  to  the 
section  on  the  Etiology  of  the  Acquired  Forms 
shows  the  different  causes  of  this  deformity.  The 
principal  ones  are  paralysis,  rhachitis,  ankle-joint 
disease,  rheumatism,  and  it  is  common  in  growing- 
boys  and  girls,  as  well  as  in  certain  occupations 
requiring  long  standing  in  one  position. 

It  also  occurs  secondarily  in  knock-knee  and 
traumatism.  In  talipes  valgus  pain  is  a  very 
prominent  symptom,  and  many  cases  have  been 
justly  described  as  "  inflammatory  flat-foot."  The 
general  changes  found  in  the  acquired  forms  con- 
sist essentially  of  a  flattening  of  the  arch  of  the 
foot,  the  weight  of  the  body  falling  mostly  upon 
its  inner  side.  This  brings  the  scaphoid  and  inter- 
nal cuneiform  bones  closer  to  the  ground,  and  it  is 
at  these  points  that  the  patients  complain  greatly 
of  pain.     The  astragalus  may  also  be  displaced  in 


68 


MEMOIR  OF  A.  S.  ROBERTS. 


the  same  direction.  In  some  cases  there  are  mus- 
cular contractions,  the  contraction  taking  place  in 
the  abductors,  the  adductors  being  in  a  condition 
of  paresis.  Where  the  cases  occur  as  a  result  of 
infantile  paralysis,  the  tibialis  anticus  is  usually 
affected,  more  rarely  the  tibialis  posticus,  and  in 
these  cases  in  which  the  paralysis  is  of  long  stand- 
ing or  extensive,  the  prognosis  is  unfavorable.  The 
cases  are  always  tedious,  necessitating  a  long  time 
for  their  cure,  but  otherwise,  as  a  class,  talipes  val- 
gus of  the  acquired  form  is  usually  relieved  by 
treatment. 

Fig.  2. 


Talipes  equinus. 

Talipes  Equinus  (see  Fig.  2).  Synonyms :  Ger., 
Pferdefuss,  Sjritzfuss;  Fr.,  Pied-bot  equin.  This 
may  be  a  congenital    or  acquired   deformity,  but 


CLUB-FOOT:   TALIPES. 


69 


congenitally  it  occurs  very  rarely,  Little  and  Broad- 
hurst  stating  that  they  had  seen  but  two  cases,  and 
Tamplin,  according  to  Adams,  discredits  it  entirely 
as  a  congenital  deformity.  In  a  typical  case  the 
foot  should  be  extended,  the  patient  walking  on  the 
ball  of  the  toes.  The  acquired  form  of  talipes 
equinus  is,  on  the  contrary,  a  very  frequent  deform- 
ity;  especially  is  this  true  of  the  paralytic  form. 

Fig.  3. 


Severe  talipes  equinus. 


The  most  frequent  cause  of  the  deformity  is 
found  in  infantile  spinal  paralysis.  Its  influence  in 
the  production  of  the  different  forms  of  talipes,  and 
the  explanations  have  been  mentioned  under  the 
section  on  Etiology.  Other  causes  are  found  in 
spastic  paralysis,  neuro-mimesis,  post-hemiplegic 
contractions,  wounds,  cicatrices,  and  long-continued 
decubitus. 

In  this  form  of  talipes  the  os  calcis  is  raised,  and 
may  even  be  in  direct  contact  with  the  tibia.     The 


70  MEMOIR  OF  A.  S.  ROBERTS. 

astragalus  is  displaced  downward,  showing  as  a 
prominence  on  the  dorsum  of  the  foot.  Where  the 
deformity  has  advanced  there  occurs  a  decided 
bend  at  the  transverse  tarsal  articulation,  and  the 
scaphoid  is  brought  in  contact  with  the  os  calcis. 

Fig.  4. 


Severe  talipes  equinus. 

In  the  severer  forms  there  is  also  a  marked  contrac- 
tion of  the  plantar  arch,  these  cases  constituting 
the  pes  cavus  of  some  authors.  Where  the  patient 
has  extended  the  toes  in  walking,  the  proximal 
phalanges  form  articulations  with  the  superior  sur- 
faces, of  the  metatarsal  bones.  In  some  old  cases 
where  the  deformity  was  allowed  to  exist  without 
interference,  the  bones  after  death  have  been  found 
very  light  and  cancellous. 

The  ligaments  are  contracted  upon  the  plantar 


CLUB-FOOT i   TALIPES. 


71 


surface,  and  elongated  upon  the  dorsum  of  the  foot. 
Adams  found  the  astragalo-scaphoid  ligament  much 
lengthened,  as  also  the  interosseous  and  calcaneo- 


astragaloid  ligaments. 


Fig.  5. 


Talipes  calcaneus. 


The  muscles  involved  are  the  posterior  ones,  the 
gastrocnemius,  plantaris,  and  soleus  acting  through 
the  tendo  Achillis.  Pancoast  asserts  that  the  soleus 
is  chiefly  at  fault,  and  has  operated  upon  this  mus- 
cle ;  but  extension  and  flexion  at  the  knee-joint  so 
affect  this  deformity,  increasing  or  lessening  it,  as 


72  MEMOIR  OF  A.  S.  ROBERTS. 

to  show  the  marked  influence  of  those  muscles 
attached  to  the  condyles  of  the  femur. 

The  prognosis  in  talipes  equinus  is  very  favor- 
able, patients  having  been  relieved  of  the  deformity 
at  all  ages. 

The  diagnosis  is  easily  made,  the  only  difficulty 
being  at  times  the  discovery  of  the  cause.  The 
history  of  the  case  will  generally  decide  this.  Its 
appearance  is  diagnostic,  and  by  simply  raising  the 
leg  with  the  patient  in  a  sitting  position,  the  knee 
being  depressed,  the  amount  and  character  of  the 
deformity  will  be  easily  ascertained.  Care  should 
be  taken  not  to  allow  flexion  at  the  knee-joint,  for 
if  this  be  permitted,  the  posterior  muscles  will  allow 
more  flexion  at  the  ankle-joint,  so  that  if  the  de- 
formity be  slight  it  will  disappear,  thus  showing 
that  false  conclusions  as  to  the  amount  of  the 
deformity  have  been  reached. 

Talipes  Calcaneus.  Synonyms :  Ger.,  Hacken- 
fass ;  Fr.,  Pied-bot  talus.  As  a  primitive  deformity 
it  is  the  rarest  of  all  varieties.  In  this  condition 
we  have  the  direct  opposite  of  the  equinus  form. 
The  foot  is  flexed  upon  the  leg,  its  dorsum  ap- 
proaching the  tibia ;  while  the  heel  is  lowered,  and 
the  sole  of  the  foot  elevated  (Fig.  5).  Here  the 
displacement  occurs  at  the  tibio-astragaloid  articu- 
lation, and,  as  in  equinus,  upon  an  antero-posterior 
plane. 

in  the  congenital  form  the  bones  are  not  much 
altered.  The  astragalus  seems  to  be  drawn  back- 
ward and  its  neck  more  in  contact  with  the  tibio- 
fibular surfaces,  while  the  anterior  part,  superiorly, 


CLUB-FOOT:   TALIPES. 


73 


is  posterior  to  the  tibia.  The  os  calcis  follows  the 
oblique  direction  of  the  astragalus,  and  becomes 
vertical  in  its  position. 

The  acquired  form  is  also  very  rare,  and  is  usually 
the  result  of  infantile  spinal  paralysis,  affecting  the 
posterior  calf  muscles  (Fig.  6).     Other  causes  are 

Fig.  6. 


Paralytic  talipes  calcaneus. 

injuries,  too  rapid  stretching  of  the  tendo  Achillis 
after  tenotomy,  and  disease  in  the  neighborhood  of 
the  ankle-joint. 

In  addition  to  the  bony  changes  described  under 
the  congenital  forms,  there  is  an  exaggeration  of  all 
the  displacements  there  mentioned.  The  ligaments 
posterior  to  the  ankle  are  lengthened,  and  contracted 
upon  the  front  and  upon  the  plantar  surface,  the 
plantar  fascia  being  contracted.     The  muscles  in- 


74  MEMOIR  OF  A.  S.  ROBERTS. 

volved  are  the  extensor  proprius  pollicis  and  longus 
digitornm,  as  also  the  tibialis  anticus.  The  pero- 
nens  tertius  may  also  be  involved.  The  deformity  is 
easily  diagnosticated,  and  the  prognosis  is  favorable 
in  congenital  cases,  and  while  this  is  not  so  true  of 
the  acquired  variety,  great  relief  may  be  obtained 
by  suitable  orthopedic  appliances. 

It  will  be  unnecessary  to  give  in  this  article 
elaborate  accounts  of  pes  cavus  or  pes  planus. 

In  the  former,  pes  cavus,  there  is  simply  an 
increased  concavity  of  the  plantar  arch,  while  the 
dorsal  convexity  is  abnormally  prominent.  It  may 
be  a  congenital  or  acquired  variety,  the  latter  being 
much  more  frequent. 

Pain  is  a  very  prominent  symptom  in  this  class 
of  cases,  and,  the  pressure  coming  upon  the  heads 
of  the  metatarsal  bones  and  the  heel,  callosities  and 
corns  form  which  are  very  painful.  Walking  in 
many  cases  is  accomplished  with  the  greatest  diffi- 
culty, owing  to  the  pain,  and  the  gait  is  charac- 
teristic. 

Pes  planus  is  considered  by  many  authors  as 
simply  a  spurious  valgus.  Here  the  depression  is 
localized  on  the  inner  side  of  the  plantar  arch,  but 
without  the  eversion  of  the  sole.  It  is  very  common 
in  certain  races,  and  the  negro  is  peculiarly  liable 
to  this  deformity.  Infants,  as  a  rule,  have  flat  feet, 
but  the  arch  is  developed  when  they  begin  to  walk. 
None  of  the  anatomical  changes  noted  in  typical 
valgus  occur  in  this  condition,  excepting,  perhaps, 
those  cases  in  which  the  deformity  has  existed  for  a 
long  lime,  when  a  true  valgus  may  ensue. 


CLUB-FOOT:   TALIPES. 


75 


The  symptoms  are  very  similar  to  those  of  valgus, 
and  pain  is  in  many  cases  present. 

In  this  condition  we  do  not  have  the  eversion  of 
the  sole,  nor  is  there  the  abnormal  condition  of  the 
astragalo-scaphoid  articulation,  such  as  we  see  in 


the  true  valgus. 


Fig.  7. 


Paralytic  talipes  equino-varus. 

Compound  Forms  of  Club-foot.  In  these  forms 
of  club-foot  we  may  have  an  association  of  all  the 
primitive  types  of  the  deformity.  When,  therefore, 
we  speak  of  a  compound  club-foot,  we  refer  to  a 
deformity  having  the  characteristic  qualities  of  two 


76  MEMOIR  OF  A.  S.  ROBERTS. 

or  more  of  the  primitive  types.     Thus,  most  fre- 
quently we  meet 

Talipes  equino-varus  (Fig.  7),  in  which  we  find 
extension  and  adduction  combined,  the  deformity 
taking  place  both  on  an  antero-posterior  and  on  a 
lateral  plane.  As  a  congenital  deformity  this  com- 
pound form  is  the  most  frequent  of  all  the  varieties 
of  club-foot,  and  is  met  with  in  every  degree  of 
severity.  Authors  have  attempted  to  divide  these 
degrees,  but,  like  the  stages  of  morbus  coxarius, 
they  are  more  arbitrary  than  real,  and  have  no  prac- 
tical importance.  The  morbid  anatomy  shows  the 
os  calcis  drawn  upward,  from  the  horizontal  to  a 
more  vertical  position.  It  is  also  rotated  on  its 
vertical  axis,  and  its  aniterior  extremity  directed 
inward,  its  posterior  extremity  pointing  outward 
and  toward  the  fibula.  The  cuboid,  maintaining  its 
relation  to  the  os  calcis,  follows  the  inward  direction 
of  its  anterior  part.  The  astragalus  follows  the  os 
calcis  forward,  so  that  the  posterior  portion  of  its 
superior  articular  surface  is  in  contact  with  the 
inferior  articular  surface  of  the  tibia,  the  anterior 
part  of  its  articular  facet  projecting  at  the  dorsum 
of  the  foot.  The  shape  of  the  astragalus  may  be  so 
much  altered  by  these  changes  that  the  anterior 
articular  surface  looks  inward  instead  of  forward. 
The  scaphoid  bone  is  drawn  inward,  upward,  and 
backward,  carrying  with  it  the  cuneiform  bones,  tho 
metatarsal  bones  retaining  their  relation  to  the  tarsi, 
being  displaced  inward.  Many  authors  have  written 
upon  the  deficiency  of  the  inner  malleolus,  consid- 
ering it  to  be  one  of  the  causes  of  the  deformity. 


CLUB-FOOT:   TALIPES. 


77 


Neither  Little  nor  Adams  has  found  this  in  his 
dissections.  The  question  of  these  changes  being 
primary  or  secondary  has  already  been  discussed  in 
speaking  of  the  etiology. 


Fig.  8. 


Double  congenital  equino-varus. 

The  ligaments  at  birth  show  very  little  alteration 
in  structure,  but  in  more  advanced  cases  the  plantar 
ligaments  are  contracted,  as  also  the  internal  lateral 
and  posterior  ligaments.  These  may  offer  great 
resistance  to  eversion  of  the  foot,  and  Adams  has 
shown  that  the  anterior  portion  of  the  internal  lat- 
eral ligament,  passing  from  the  malleolus  to  the 
scaphoid  bone,  may  render  this  particularly  difficult. 

The  muscles  at  birth  show  no  particular  changes, 
and  although  the  limb  on  the  affected  side  is  gener- 


78  MEMOIR  OF  A.  S.  ROBERTS. 

ally  smaller  than  its  fellow,  the  muscles  themselves 
are  normal,  but  undeveloped.  It  is  important  to 
remember  that  in  consequence  of  the  altered  rela- 
tions of  the  bones,  the  tendons  may  be  much  dis- 
placed. Thus  the  tendo  Achillis  is  more  external, 
being  nearer  the  fibula,  the  tibialis  posticus  more 
forward  and  inward,  and  further  separated  from  the 
tendo  Achillis. 

Fig.  9. 


Severe  congenital  equine- varus . 


Little  has  given  the  position  of  the  tibialis  posti- 
cus as  being  "  exactly  midway  between  the  anterior 
and  posterior  borders  of  the  leg  on  its  inner  aspect." 
The  tendons  running  in  front  of  the  ankle-joint  pass 
near  to  the  inner  side,  that  of  the  tibialis  anticus 
pissing  over  the  inner  malleolus.  The  vessels  and 
nerves  follow  the  deformity,  but  retain  their  relations 
to  the  tendons. 


CLUB  FOOT:    TALIPES.  79 

In  this  class  of  cases  the  prognosis  is  generally 
favorable,  although  the  varus  is  much  more  amen- 
able to  treatment  than  the  equinus. 

The  acquired  form  of  the  compound  deformity  is 
also  very  frequent,  being  most  commonly  due  to 
infantile  spinal  paratysis.  Other  causes  may  be 
found  in  those  already  given  in  the  description  of 
talipes  equinus.  The  morbid  changes  follow  closely 
the  description  given  above  of  the  congenital  form. 
The  prognosis,  especially  when  the  cause  is  a  cen- 
tral one,  is  much  more  unfavorable,  this  being  readily 
appreciated  when  we  consider  the  destruction  of  the 
cells  in  the  cord.  We  have  written  of  this  com- 
pound deformity  at  some  length,  because  it  is 
undoubtedly  the  most  frequent  of  all  forms  of  club- 
foot, and  also  is  the  most  difficult  of  treatment. 

HJquino-valgus  simply  consists  of  the  combination 
of  the  two  primitive  forms,  equinus  and  valgus,  and 
for  the  morbid  changes  the  reader  is  referred  to  the 
description  of  these  two  varieties. 

Calcaneo-varus  and  valgus  are  such  rare  forms  of 
talipes  that  little  is  necessary  for  their  description. 
A  study  of  the  component  simple  forms  entering 
into  their  formation  is  all  that  is  necessary  for  their 
diagnosis,  morbid  changes,  and  treatment. 

Non-deforming  Club-foot.  For  a  full  description 
of  the  very  interesting  form  of  cases  designated  by 
Dr.  Shaffer,  of  New  York,  as  "  Non-deforming 
Club-foot,"  the  reader  is  referred  to  the  New  York 
"Medical  Record"  for  May  23,  1885,  where  an 
account  of  their  characteristics  and  pathology,  with 
some  remarks  on  treatment,  is  given.     Dr.  Shaffer 


80 


MEMOIR  OF  A.  S.  ROBERTS. 


has  undoubtedly  described  a  new  class  of  cases, 
practically  unknown  or  unrecognized  by  other  ob- 
servers (Fig.  10).  Here  we  shall  only  allude  to  the 
condition  briefly.  Dr.  Shaffer  says,  "  In  non-deform- 
ino-  club-foot  all   the  conditions   found  in  certain 

Fjg.  10. 


Non-deforming  club-foot. 


forms  of  talipes  exist  with  the  exception  of  the 
exaggerated  deformity.  That  is,  there  is  a  loss  of 
normal  relation  between  the  articulation  at  the  ankle 
and  the  muscles  which  act  upon  it,  involving  also 
in  many  instances  the  tarsus,  producing  a  condition 


CLUB-FOOT:   TALIPES.  81 

which  prevents  normal  flexion  at  the  ankle-joint, 
and  modified  mobility,  with  slight  deformity  at 
the  tarsal,  metatarsal,  and  phalangeal  articulations. 
"With  this  state  of  affairs  we  find,  as  a  result,  vary- 
ing with  the  conditions  present,  actual  disability, 
pain,  sometimes  very  severe,  in  various  parts  of  the 
foot,  ankle,  leg,  and  even  reflected  to  the  lumbar 
region,  and  tender  and  inflamed  articular  surfaces, 
especially  at  the  junction  of  the  first  metatarsal 
bone  with  its  phalanx.  If  these  effects  be  wanting, 
we  have  only  an  awkward  or  peculiar  gait  associated 
with  painful  callosities  and  corns  at  various  points 
upon  the  foot."  Furthermore,  he  says,  "  Non- 
deforming  club-foot  may  occur  at  any  age.  I  have 
seen  it  in  infancy,  when  doubtless  its  etiology  is 
the  same  as  that  of  congenital  club-foot.  It  occurs 
rarely  as  an  acquired  condition  in  children,  though 
often  the  '  good  result '  of  many  surgeons  after  ten- 
otomy and  treatment  leaves  behind  it  a  condition 
like  that  I  have  attempted  to  describe.  It  is  seen 
very  frequently  during  the  period  of  second  growth 
— the  adolescent  period — in  both  sexes,  when  at 
that  particular  age  there  are  not  apt  to  be  many 
important  sequelae.  It  usually  does  not  reach  its 
full  development  until  adult  life  and  full  growth  is 
attained.  It  occurs  more  frequently  in  the  female 
sex,  and  ivhen  looked  for,  is  found  sometimes  in 
rapidly  growing  girls,  and  especially  in  those  whose 
growth  has  been  apparently  arrested  before  the 
average  height  is  reached.  And  what  is  very  im- 
portant and  to  a  certain  extent  remarkable  is  this : 
it  is  found  very  often  associated  ivith  true  rotary 


82  MEMOIR  OF  A.  S.  ROBERTS. 

lateral  curvature  of  the  spine.  We  may  have  a  con- 
dition of  non-deforming:  club-foot  from  five  different 
causes:  1,  Non-deforming  club-foot  seen  after  polio- 
myelitis anterior ;  2,  non-deforming  club-foot  which 
follows  simple  and  uncomplicated  malposition,  habit, 
etc.;  3,  non-deforming  club-foot  produced  by  trau- 
matism, sprains,  etc.;  4,  non-deforming  club-foot 
found  after  the  infectious  diseases  of  childhood, 
especially  diphtheria  and  scarlet  fever ;  5,  the  non- 
deforming  club-foot  due,  as  I  believe,  to  some  remote 
trophic  disturbance,  and  seen  quite  frequently  co- 
existing with  true  lateral  curvature." 

All  the  forms  which  have  been  described  may  be 
simulated  by  the  so-called  " neuromimeiic"  or  hysteri- 
cal club-foot.  Their  diagnosis  is  always  surrounded 
with  difficulty,  and  the  differentiation  of  the  symp- 
toms demands  great  caution.  The  treatment,  once 
the  diagnosis  is  clear,  should  be  addressed  mainly 
to  the  neural  symptoms  and  the  general  "  morale  " 
of  the  patient.  It  may  become  necessary,  all  other 
means  having  failed,  to  divide  contracted  tendons, 
as  instanced  in  a  case  in  which  we  divided  the  tendo 
Achillis.  This  case  is  related  by  S.  Weir  Mitchell 
in  his  "  Lectures  on  Diseases  of  the  Nervous  Sys- 
tem" (Philadelphia,  1885,  p.  129). 

Treatment.  In  beginning  the  treatment  of  a 
case  of  club-foot  the  surgeon  should  have  in  view 
two  principal  objects :  first,  the  removal  of  the  de- 
formity ;  second,  the  restoration  of  the  functions  of 
the  foot.  To  accomplish  this,  many  and  various 
devices  have  been  resorted  to,  and  a  history  of  these 
would  furnish  an  interesting  chapter  to  the  subject. 


CLUB-FOOT:   TALIPES.  83 

It  will  be  impossible  in  a  limited  space  to  describe 
all  the  methods  which  have  been  used  by  surgeons 
in  the  treatment  of  club-foot,  and  it  will  be  neces- 
sary to  discuss  only  such  as  are  in  common  use  at 
present,  and  embody  the  most  scientific  principles 
for  the  removal  of  the  deformity.  The  remarks  of 
Adams  are  here  very  appropriate.  "  The  scientific 
treatment  of  talipes  varus,  when  severe,  as  of  several 
other  deformities  of  the  limbs,  can  only  be  accom- 
plished by  a  judicious  combination  of  the  operative, 
mechanical,  and  physiological  means,  while  many  of 
the  failures  still  witnessed  in  the  practice  of  those 
who  have  not  devoted  much  attention  to  the  subject 
are  due  to  the  want  of  this  combination  of  principles, 
too  frequently  considered  as  antagonistic  to  one 
another,  but  which  modern  science  teaches  us  are 
only  reliable  in  so  far  as  their  mutual  dependence 
is  recognized  and  applied  by  the  scientific  insight 
of  the  surgeon." 

The  general  treatment  of  club-foot  is  best  divided 
into : 

I.  The  Mechanical. 

II.  The  Operative. 

Under  the  head  of  mechanical  means  are  in- 
cluded : 

1.  Manipulations;  their  object  being  to  stretch 
the  foot  to  its  normal  position.  These  may  consist 
of  passive  motions,  shampooing,  and  the  "kneading" 
of  the  part.  The  importance  of  the  hand  as  an  in- 
strument for  the  correction  of  the  deformity  cannot 
be  too  strongly  insisted  upon,  and  the  best  appa- 
ratus is  that  which  closely  follows  its  action.    "The 


84  MEMOIR  OF  A.  S.  ROBERTS. 

hand,"  says  Bouvier,  "is  the  ideal  of  mechanical 
means  for  reducing  the  deformity." 

2.  Massage  and  Electricity.  These  are,  strictly 
speaking,  physiological  means,  but  as  their  applica- 
tion is  mechanical,  we  have  placed  them  under  that 
heading.  These  agents,  as  applied  especially  to  the 
paralytic  forms,  will  be  found  referred  to  in  another 
portion  of  this  work  (see  article  Infantile  Paralysis). 

3.  Splints.  The  use  of  splints  embodies  the  ap- 
plication of  such  mechanical  principles  as  will  serve 
to  correct  the  disturbed  form  of  the  foot.  They 
may  be  used  as  permanent  unyielding  dressings, 
i.  e.,  plaster  of  Paris  or  silicate  of  soda ;  or  they 
may  utilize  elastic  force,  as  in  the  apparatus  of 
Barwell  and  Sayre ;  or,  finally,  they  may  combine 
extension  with  fixation,  as  seen  in  the  various  modi- 
fications and  improvements  on  Scaipa's  shoe. 

The  operative  treatment  of  club-foot  consists  of: 
1.  Tenotomy,  or  division  of  contracted  tendons. 
The  proper  time  for  the  performance  of  tenotomy 
has  been  the  cause  of  much  difference  of  opinion, 
some  advocating  its  immediate  performance,  and 
others  deferring  it  until  such  time  as  the  patient  is 
able  to  walk.  In  the  majority  of  cases  the  early 
operation,  if  the  case  be  of  such  a  nature  as  to  pre- 
clude the  possibility  of  cure  by  simple  mechanical 
means,  is  to  be  preferred.  Experience  alone  can 
give  the  best  indications  for  the  operation,  the 
presence  of  rigidity,  reflex  spasm  (Sayre),  or  an 
excessive  amount  of  deformity  not  being  in  them- 
selves  sufficient  reasons.  The  patient  application 
of  mild  means  should  always  be  attempted  before 


CLUB-FOOT:   TALIPES.  85 

the  performance  of  an  operation,  however  slight  it 
may  seem  to  the  surgeon. 

Modes  of  Operating.  Tendons  and  fasciae  are 
most  conveniently  divided  from  below  toward  the 
skin,  but  some  surgeons  prefer  to  insert  the  knife 
between  the  tendon  and  the  skin  and  cut  inward. 
The  latter  method,  where  the  relation  of  the  vessels 
and  nerves  is  much  disturbed,  is  attended  with  con- 
siderable danger.  The  form  of  tenotome  used  is 
largely  a  matter  of  choice ;  as  a  rule,  only  two  are 

Fig.  11. 


Position  for  performance  of  tenotomy.     (From  Sayre.) 


necessary.  The  best  tenotomes  for  ordinary  use 
should  be  one  with  a  straight  blade  and  sharp  point 
for  making  the  skin  puncture,  and  another  with  a 
probe- point  for  completing  the  section  of  the  tendon. 
The  handles  should  be  round,  flattened  upon  the 
surface  corresponding  to  the  dorsum  of  the  blade. 
The  patient,  having  been  anesthetized,  is  placed 
upon  the  table  in  a  convenient  position  and  in  a 


86  MEMOIR  OF  A.  S.  ROBERTS. 

good  light,  and  one  assistant  grasping  the  part  to 
be  operated  firmly,  the  other  places  the  limb  not  to 
be  operated  upon  out  of  the  Avay  (see  Fig.  11). 
The  preparatory  puncture  having  been  made  with 
the  sharp-pointed  knife,  the  operator  introduces  the 
probe-pointed  tenotome  flatwise,  as  close  to  the 
tendon  as  possible,  and  beneath  it,  and,  its  cutting 
edge  being  then  turned  toward  the  tendon,  a  saw- 
ing motion  is  imparted  to  the  tenotome,  and  the 
tendon  carefully  divided.  An  assistant  should 
firmly  tighten  the  tendon  during  the  operation,  and 
as  the  section  approaches  completion  relax  his  hold 
on  the  part  gradually.  As  tendons  differ  very  much 
in  their  resistance,  this  precaution  is  very  necessary, 
as  otherwise,  if  not  observed,  the  tenotome  would 
be  very  likely  to  cut  through  the  skin. 

After  the  division  of  the  tendon  the  knife  is  with- 
drawn and  slight  pressure  made  over  the  wound.  A 
pad  of  lint  fixed  with  adhesive  plaster  is  placed  over 
it,  and  the  foot  and  leg  bandaged.  The  immediate 
care  of  the  foot  after  tenotomy  is  a  source  of  much 
difference  of  opinion.  Many  surgeons  believe  in 
immediate  restoration  of  the  foot  to  its  normal  posi- 
tion. Others  bandage  it  to  a  splint  in  the  deformed 
or  slightly  less  deformed  position,  and  gradually 
restore  the  limb  during  the  process  of  cicatrization. 
In  our  opinion  the  application  of  such  apparatus  as 
will  give  the  surgeon  complete  control  of  the  parts, 
and  at  the  same  time  allow  extension,  according 
to  the  activity  in  the  reparative  process,  is  most 
desirable. 

Several  accidents  may  happen  in  the  performance 


CLUB-FOOT:   TALIPES.  87 

of  tenotomy.  Among  these  are,  division  of  the 
skin,  making*  an  open  wound ;  wounding  of  the 
posterior  tibial  or  internal  plantar  artery;  false 
aneurism  and  inflammation  in  the  sheath  of  the 
tendon,  or  imperfect  union  of  the  tendon.  These 
are  to  be  treated  according  to  ordinary  surgical 
principles. 

Adams  has  given  a  resume  of  the  different  ac- 
counts of  the  reparative  process  in  the  tendons, 
such  as  were  found  by  Hunter,  Mayo,  Von  Am- 
nion, Guerin,  Pirogoff,  Koerner,  Paget,  and  others. 
These  observations  show  that  the  space  between 
the  divided  ends  of  the  tendon  soon  becomes  filled 
up  by  plastic  matter  and  serum ;  that  in  this  new 
matter  bloodvessels  multiply  rapidly,  the  new  tissue 
surrounding  the  divided  ends  as  callus  unites  the 
ends  of  fractures.  This  becomes  changed  into 
connective  tissue  and  firm,  and  combining  with  the 
intermediate  substance  contracts  gradually,  assum- 
ing as  it  does  the  character  of  new  tendon. 

2.  Myotomy.  Little  need  be  said  of  this  pro- 
cedure. It  is  scarcely  ever  done.  Professor  Joseph 
Pancoast,  of  Philadelphia,  believed  in  the  sole  action 
of  the  soleus  muscle  in  the  production  of  equinus, 
and  divided  the  muscle  for  the  relief  of  this  de- 
formity, but  the  operation  has  never  come  into 
general  use. 

3.  Tarsotomy  and  Tarsectomy.  The  first  men- 
tioned procedure  is  the  division  of  such  bony  struc- 
tures as  are  involved  in  the  deformity  by  means  of 
the  osteotome,  the  second  consisting  of  the  removal 
of  a  wedge-shaped  piece  of  the  bones.     When  we 


88  MEMOIR  OF  A.  S.  ROBERTS. 

consider  how  seldom  these  operations  seem  to  be 
necessary,  it  is  somewhat  surprising  that,  as  was 
recently  shown  by  Lorenz,  fourteen  operations  have 
been  devised,  exclusive  of  tenotomy,  for  the  cor- 
rection of  talipes.     They  are :  1,  Linear  osteotomy 
of  the  scaphoid  practised  on  the  plantar  surface 
(Hahn) ;  2,  linear  osteotomy  of  the  tibia  above  the 
malleolus   (Hahn) ;    3,   enucleation   of  the    cuboid 
(Solly);    4,    enucleation    of   the   astragalus    alone 
(Lund,  Maron);  5,  the  same  with  the  resection  of 
the  tip  of   the  external  malleolus   (Maron,   Keid) ; 
6,  excavation  of  the  spongy  portion  of  the  astrag- 
alus, leaving  the  articular  surfaces  ( Verebely) ;  7, 
enucleation  of  the  astragalus,   and  excision  of  a 
wedge-shaped  piece  from  the  anterior  portion  of  the 
os  calcis   (Hahn);  8,  enucleation  of  the  astragalus 
and  cuboid  (Albert  and  Hahn),  or  of  the  astragalus 
and  scaphoid  (West);  9,  enucleation  of  the  astrag- 
alus, cuboid,  and   scaphoid    (West);    10,  enuclea- 
tion  of  the   scaphoid   and   cuboid    (Bernet);    11, 
resection  of  the  head   of  the  astragalus    (Liicke, 
Albert)  ;  12,  excision  of  a  wedge  from  the  outer 
half  of  the  neck  of  the  astragalus   (Hueter) ;   13, 
excision  of  two  wedges,  perpendicular  to  each  other, 
with  bases  at  Chopart's  articulation,  and  the  astrag- 
alo-calcanean  joint  (Rydygier)  ;  14,  excision  of  a 
wedge  without  regard  to  any  individual  bones  (O. 
Weber,  Davies-Colley,  R.  Davy).      In  the  experi- 
ence of  the  authors    these    operations    are   rarely 
necessary,  and,  perhaps,  only  applicable  in   adult 
eases  which  have  resisted  all  other  forms  of  treat- 
ment, or  in  relapsed  cases  in  which  the  inflammatory 


CLUB-FOOT:   TALIPES.  89 

products  have  so  agglutinated  the  different  struc- 
tures as  to  render  other  measures  impossible.  For 
a  full  description  of  these  different  surgical  proced- 
ures the  reader  can  consult  the  special  treatises, 
and  also  the  article  of  Davies-Colley  ("Transac- 
tions of  the  Medico-Chirurgical  Society,"  vol.  lx. 

p.  ii). 

4.  Brisement  Force.  Under  this  procedure  are 
classed  all  operations  which  have  for  their  object 
the  immediate  restoration  of  the  form  of  the  foot, 
either  by  the  hand  or  by  powerful  instruments. 

5.  Multiple  Tenotomy  and  Open  Incision.  The 
division  of  all  the  contracted  tendons  at  one  sitting- 
has  been  performed,  but  has  not  met  with  general 
approbation,  owing  to  the  fact  that  no  appropriate 
point  of  resistance  is  left  afterward  that  can  be 
utilized  for  mechanical  treatment.  Indeed,  although 
it  is  the  practice  of  English  surgeons  to  divide 
many  tendons,  the  tenotomy  in  this  country  is 
usually  limited  to  the  tendo  Achillis",  plantar  fascia, 
and  tibialis  anticus  and  posticus. 

Open  incision  has  recently  been  commended  by 
Drs.  Phelps  and  Hingston.  A  more  extensive 
experience  in  this  procedure  will  best  decide  its 
relative  merits. 

6.  Amputation.  As  a  dernier  ressort  in  severe 
paralytic  cases,  in  which  the  patient  prefers  an  arti- 
ficial foot,  and  where  all  ordinary  means  have  been 
exhausted,  amputation  has  occasionally  been  per- 
formed. 

Treatment  of  Special  Varieties.  Having 
finished  the  general  remarks  on  the  treatment  of 


90  MEMOIR  OF  A.  S.  ROBERTS. 

club-foot,  we  will  now  proceed  to  give  an  account 
of  the  special  varieties. 

Talipes  Varus.  Pure  varus,  either  as  a  congeni- 
tal or  acquired  deformity,  occurs  so  infrequently 
that  a  consideration  of  the  principles  involved  in  its 
treatment,  and  the  means  employed,  had  best  be 
deferred  until  we  arrive  at  the  treatment  of  talipes 
equino-varus. 

Talipes  Valgus.  Congenital  cases,  treated  soon 
after  birth,  may  be  cured  by  manipulations  alone, 
these  having  for  their  object  the  carrying  of  the 
foot  to  a  more  inverted  position.  To  retain  the  foot 
in  a  good  position  after  these  movements,  adhesive 
plaster  (Maw's)  with  a  roller  bandage  may  be  em- 
ployed. Where  the  deformity  is  rather  more  severe, 
external  splints  of  a  simple  character,  composed  of 
tin,  gutta-percha,  or  hatter's  felt,  may  be  used. 
These  are  moulded  to  the  part,  and  a  gradual  inver- 
sion of  the  foot  accomplished.  The  application  of 
massage  and  electricity  to  the  weakened  anterior 
tibial  muscle  may  be  resorted  to  with  advantage, 
and  rest  should  also  be  enjoined.  In  the  more 
severe  forms  of  congenital  valgus  tenotomy  of  the 
peronei  and  extensor  longus  digitorum  occasionally 
becomes  necessary. 

In  acquired  valgus  the  treatment  also  varies  with 
the  amount  of  the  deformity  and  cause.  In  mild 
forms  unattended  by  contraction  of  tendons,  the 
application  of  a  simple  ankle  support,  composed  of 
two  lateral  uprights  connected  with  a  band  to  en- 
circle the  calf,  and  with  an  inner  pad  corresponding 
to  the  axis  of  the  astragalo-scaphoid  articulation, 


CLUB-FOOT:   TALIPES.  91 

and  attached  to  the  bottom  of  a  shoe,  may  be  used. 
In  the  majority  of  cases  additional  support  may  be 
obtained  by  the  insertion  of  a  tempered  steel  sole 
into  the  shoe,  so  moulded  that  its  convexity  has  a 
direct  bearing  upon  the  weakened  plantar  arch  (see 

Fig.  12. 


Ankle  support  for  valgus. 

Fig.  12).  In  this  condition  Drs.  Barwell  and  Sayre 
advocate  the  use  of  elastic  bands  to  supply  the 
action  of  the  weakened  tibialis  anticus  muscle.  In 
addition,  where  the  means  above  referred  to  cannot 
be  procured,  good  results  may  be  obtained  by  the 


92  MEMOIR  OF  A.  S.  ROBERTS. 

use  of  plaster-of-Paris  or  silicate  of  soda  splints, 
moulded  to  the  foot  in  a  position  of  varus  and 
allowed  to  set,  care  being  taken  to  remove  them 
from  time  to  time,  when  the  parts  should  be  care- 
fully inspected,  and  the  splint  readjusted  to  the 
corrected  deformity.  In  this  connection,  as  the 
treatment  for  the  two  conditions  is  the  same,  talipes 
planus  or  spurious  valgus  may  be  considered.  Here 
there  being  a  simple  giving  way  of  the  arch,  due 
to  relaxation  of  the  ligaments  and  plantar  fascia, 
it  is  only  necessary  to  supply  this  deficiency  by 
a  tempered  steel  sole  inserted  in  the  shoe.  In 
more  pronounced  forms,  approaching  in  char- 
acter true  valgus,  the  same  treatment  as  was  ad- 
vocated in  speaking  of  talipes  valgus  will  be  neces- 
sary. 

Talipes  JSquinus.  This  form  of  club-foot  occur- 
ring so  infrequently  as  a  congenital  deformity,  it 
will  not  be  necessary  to  describe  any  special  treat- 
ment for  its  relief.  We  will,  therefore,  proceed  at 
once  to  a  consideration  of  the  acquired  form.  The 
most  frequent  cause  of  acquired  equinus  being 
infantile  spinal  paralysis,  we  should  endeavor  to 
improve  the  condition  of  the  affected  muscles  by 
electricity,  massage,  etc.  The  paralysis  occurring 
in  the  flexor  muscles,  we  must  be  prepared  to 
counterbalance  the  antagonism  of  the  extensor 
muscles  by  suitable  apparatus.  The  best  method 
of  doing  this  is  accomplished  by  those  instruments 
which  combine  the  principles  of  extension  with 
fixation.  Of  these  there  are  many,  most  of  them 
being  improvements  on  the  original  Scarpa's  shoe, 


CL  UB-FOOT:   TA  LIPES. 


93 


and  we  will  revert  to  these  more  fully  when  describ- 
the  treatment  of  talipes  equino- varus. 

Talipes  Calcaneus,  Here,  as  in  most  of  the 
typical  simple  forms,  little  need  be  said  of  the  con- 
genital variety.  When  there  are  no  contractions  of 
the  anterior  tibial  muscles,  simple  manipulation  and 
passive  motion  will  easily  overcome  the  deformity. 

Fig.  13. 


Apparatus  for  talipes  calcaneus,  with  artificial  posterior 
muscle. 


When  the  deformity  is  more  severe,  an  ankle  sup- 
port, having  a  stop-joint,  preventing  motion  of 
extreme  flexion,  may  be  used,  or  a  similar  support, 
to  which  an  artificial  posterior  muscle  is  attached, 
similar  in  character  to  that  shown  in  Fig.  13.  In 
the  large  majority  of  instances  the  treatment  just 


94  MEMOIR  OF  A.  S.  ROBERTS. 

described  will  be  all  that  is  necessary ;  but  in  some 
cases  it  is  expedient  at  times  to  resort  to  tenotomy 
of  the  tibialis  anticus,  extensor  proprius  pollicis, 
longns  digitorum,  together  with  the  peroneus  ter- 
tius.  All  of  these  tendons  may  be  reached  through 
a  single  puncture  made  in  front  of  the  ankle-joint, 
close  to  the  inner  border  of  the  tendon  of  the  ex- 
tensor longus  digitorum,  care  beiug  taken  to  avoid 
the  anterior  tibial  artery.  Mechanical  support,  such 
as  has  been  already  described,  may  be  used  after 
the  operation. 

In  those  cases  which  are  due  to  infantile  spinal 
paralysis,  and  in  which  a  marked  contraction  of  the 
plantar  fascia  produces  a  "  cavus,"  it  may  be  neces- 
sary to  divide  the  contracted  fascia,  but  this  must 
be  carefully  considered,  as  many  cases  obtain  a  cer- 
tain amount  of  support  from  this  very  contraction. 
Where  the  deformity  arises  from  excessive  length 
of  the  tendo  Achillis,  the  muscles  themselves  being 
unimpaired,  a  radical  procedure  consists  in  excision 
of  the  elongated  tendon  and  suture  of  the  divided 
ends.  The  operation  is  performed  as  follows  :  An 
incision  being  made  down  to  the  tendon,  the  sheath 
is  opened  and  raised  by  a  blunt  hook  or  spatula, 
and  folded  or  pinched  between  the  fingers,  so  that 
the  amount  necessary  for  excision  may  be  accurately 
ascertained.  A  silver-wire,  silk,  or  gut  suture  is 
then  passed  through  the  tendon,  about  a  fourth  of 
an  inch  above  and  below  the  place  of  the  incision  of 
the  tendon.  This  will  prevent  the  slipping  of  the 
ends  into  the  sheath.  The  ends  are  then  approxi- 
mated, the  sutures    twisted   and    buried  into  the 


CLUB-FOOT:   TALIPES.  95 

tendon.  In  the  opinion  of  the  authors  this  will 
seldom  be  found  necessary,  although  several  suc- 
cessful instances  are  upon  record. 

Treatment  of  the  Compound  Forms.  In  the 
treatment  of  the  compound  forms  of  the  deformity, 
the  various  elements  entering  into  their  formation 
will  have  to  be  dealt  with.  Thus,  taking  for  exam- 
ple equino-varus,  we  have  to  deal  with  a  deformity 
taking  place  on  two  distinct  planes,  the  equinus 
being  on  an  antero-posterior  one,  and  corresponding 
only  with  the  tibio-astragaloid  articulation,  and  the 
varus  on  a  transverse  plane,  corresponding  to  the 
transverse  tarsal  joint.  It  is  plain,  therefore,  that 
all  appliances  intended  for  the  relief  of  the  com- 
pound forms  of  club-foot,  and  which  have  for  their 
object  the  rectification  of  both  elements  simul- 
taneously, are  essentially  false.  That  the  elements 
entering  into  the  formation  of  the  compound  forms 
should  receive  separate  treatment  has  been  especially 
emphasized  by  Dr.  Little  and  Mr.  Adams,  of  Lon- 
don. Little  has  stated  that  the  varus  or  valgus 
should  be  thoroughly  corrected  before  entering 
upon  the  treatment  of  the  antero-posterior  deformity, 
and  Adams  has  pointed  out  the  advantage  and  ad- 
visability of  using  the  os  calcis  and  contracted 
tendo  A  chillis  as  a  fixed  point  upon  which  the 
tarsus  may  be  extended,  thus  obtaining  by  these 
means  a  gradual  unfolding  of  the  deformed  foot. 

Talipes  Equino-varus.  By  far  the  largest  number 
of  cases,  both  congenital  and  acquired,  coming  under 
the  care  of  the  orthopedic  surgeon,  are  cases  of 
talipes  equino-varus,  and  we  shall  endeavor  to  give 


96  MEMOIR  OF  A.  S.  ROBERTS. 

somewhat  in  detail  the  various  methods  in  use  for 
the  treatment  of  this  deformity.  We  have  already 
pointed  out  the  advisability  of  dividing  the  treat- 
ment of  compound  forms  into  two  distinct  periods. 
Thus  in  equino-varus  our  attention  will  be  first 
directed  to  the  inversion,  or  to  the  deformity  occur- 
ring on  a  lateral  plane.  Of  the  various  methods  in 
vogue,  the  following  will  be  considered : 

1.  Manipulation,  massage,  and  electricity. 

2.  Retentive  dressings. 

3.  Extension  and  fixation. 

4.  Elastic  extension. 

5.  Tenotomy,  combined  with  extension  and  fixa- 
tion. 

6.  Brisement  force. 

7.  Tarsotomy  or  tarsectomy. 
Manipulations  and  massage  may  with  advantage 

be  used  in  the  slighter  cases  of  varus,  but  these 
agents  are  useful  in  all  cases  of  whatever  severity, 
and  the  nurse  is  to  be  especially  informed  of  the 
value  of  these  agents.  It  is  undoubtedly  a  fact 
that  much  can  be  done  with  the  hand  alone,  and 
many  cases  of  varus  have  been  cured  by  these 
simple  processes.  The  attendant  should  be  in- 
structed as  follows :  The  foot  being  firmly  grasped 
and  the  os  calcis  being  fixed,  the  anterior  part  of 
the  foot  is  to  be  gradually  brought  into  a  valgoid 
position.  This  motion  should  be  repeated  several 
times  at  short  intervals  ;  the  foot  is  then  shampooed 
and  may  be  placed  in  a  light  retention  dressing. 
The  manipulations  should  be  used  morning  and 
night,  and   the  splint  modified  as  the  amount  of 


CLUB-FOOT:   TALIPES.  97 

varus  is  corrected.  It  may  be  well  in  this  connec- 
tion to  say  a  few  words  concerning  massage.  This 
is  not,  as  is  popularly  supposed,  a  simple  rubbing 
of  the  parts,  but  consists  in  a  systematic  "  knead- 
ing" of  the  skin  and  deeper  structures.  These 
movements  should  consist  of  alternate  friction  and 
manipulation,  the  circulation  of  the  skin  being 
increased  by  pinching,  while  the  subcutaneous  cellu- 
lar tissue  and  muscles  may  be  more  deeply  grasped. 
Light  percussion  of  the  parts  will  also  be  beneficial. 
The  use  of  electricity  in  the  weakened  condition  of 
the  muscles,  but  more  especially  in  the  paralytic 
forms  of  club-foot,  is  a  most  important  adjuvant  to 
the  treatment. 

Retention  dressings  may  consist  of  simple  adhe- 
sive plaster  attached  around  the  foot  and  secured  on 
the  external  aspect  of  the  leg ;  it  should  be  grad- 
ually tightened  as  the  foot  is  everted,  the  dressing 
being  kept  in  place  by  a  roller  bandage.  This  is 
the  simplest  form  of  retentive  dressing.  Moulded 
splints  of  gutta-percha,  hatter's  felt,  sole-leather,  or 
rawhide  may  also  be  used  in  simple  cases  of  varus. 
These  articles,  being  cut  to  fit  the  parts,  are  placed 
in  hot  water  and  softened,  the  foot  being  held  in  the 
position  the  operator  wishes  to  secure.  The  sub- 
stance used  is  then  moulded  to  the  parts,  and 
secured  by  a  roller  bandage.  The  dressings  may 
be  changed  from  time  to  time  according  to  the 
improved  position.  Splints  of  plaster  of  Paris  or 
silicate  of  soda  may  be  applied  in  the  same  manner. 
As  dressings  they  have  the  disadvantage,  when  ap- 
plied as  fixed  splints,  of  not  allowing  a  careful  daily 

7 


98 


MEMOIR  OF  A.  S.  ROBERTS. 


inspection  of  the  parts,  excoriations  and  sloughs 
being  especially  liable  to  ensue.  When  they  are 
employed  it  would  seem  advantageous  to  cut  them, 
as  they  would  then  still  retain  their  retentive  prop- 
erties, and  allow  manipulation,  massage,  etc. 

Fig.  14. 


Varus  brace  applied ;  A,  before,  B,  after  the  deformity  has  been 
corrected. 


Extension  and  fixation  may  be  most  effectually 
used  in  overcoming  the  lateral  deviation  by  the  use 
of  Shaffer's  modification  of  Taylor's  ankle  support 
(see  Fig.  14,  a  and  b;  Figs.  15  and  16).  This 
consists  of  a  steel  trough  fitted  to  the  internal  aspect 


CLUB-FOOT:   TALIPES. 


99 


of  the  leg,  extending  from  the  internal  malleolus  to 
the  upper  third  of  the  tibia.  Hinged  to  this  is  the 
continuation  of  the  trough,  terminating  in  a  joint 
which  articulates  with  the  foot-plate,  allowing  antero- 
posterior motion  at  this  point.  This  joint  has  been 
added  to  Shaffer's  original  "  lateral  shoe,"  and  by 
it  we   can  adjust  it  to  a  coexisting   equinus.     A 

Fig.  15. 


Lateral  view  of  varus  brace,  applied  to  deformity. 

worm  or  endless  screw  operated  by  a  key,  and  seen 
at  a,  Fig.  14,  acting  upon  the  sole-plate  at  right 
angles  to  the  direction  of  the  hinge,  enables  the 
surgeon  to  apply  the  apparatus  accurately  to  the 
extremes  of  varus  (or  valgus),  and  by  means  of  a 
key  to  bring  the  foot  in  the  desired  position.  The 
splint  should  always  be  applied  to  the  foot  in  its 


100 


MEMOIR  OF  A.  S.  ROBERTS. 


deformed  position,  and  maintained  there  by  a  roller 
bandage,  as  seen  in  Fig.  14,  a.  Then,  by  the  use 
of  the  endless  screw  operated  by  the  key,  the  foot 
can  be  brought  into  the  corrected  position  as  seen 
in  Figs.  14,  b,  and  16.  This  simple  apparatus, 
which,  with  a  little  instruction,  can  easily  be  applied 
and  adjusted  by  the  nurse  or  parent,  allows  of  daily 
inspection,  manipulation,  and  massage.  In  the 
severer  forms  of  equino-varus,  in  which  the  lateral 

Fig.  16. 


Lateral  view  of  varus  brace,  showing  deformity  corrected. 


element  is  in  excess,  owing  to  the  marked  tarsal 
deviation  and  plantar  contraction,  the  simple  lateral 
brace  above  described  has  been  found  insufficient, 
and  Shaffer  has  for  these  cases  devised  a  more  pow- 
erful apparatus,  which  can  best  be  described  in  the 
following  personal  communication. 

"  The  success  which  has  attended  the  use  of  the 


CLUB-FOOT:   TALIPES.  101 

extension  or  traction  shoe1  in  the  treatment  of  the 
antero-posterior  deformities  of  club-foot,  led  me  to 
seek  some  method  by  which  traction  could  be 
applied  to  the  lateral  deformities  of  the  tarsus — 
and  especially  those  found  in  confirmed  cases  of 
equino-varus.  The  conventional  club-foot  shoe 
with  the  ball  and  socket  or  hinged  joint  in  the  foot- 
plate, at  a  point  corresponding  with  the  medio-tarsal 
joint,  has  proved  very  unsatisfactory,  especially  in 
cases  where  there  was  much  tarsal  deformity  or  any 
considerable  plantar  contraction.  The  limited  suc- 
cess attending  the  use  of  the  lateral  shoe 2  led  me  to 
use  this  splint  as  a  starting-point  for  further  experi- 
ment. After  various  efforts  I  have  perfected  an 
apparatus  which  may  be  described  as  follows :  To 
this  simple  lateral  shoe,  with  its  hinged  lever  and 
screw,  which  imparted  a  lateral  force  principally 
to  the  os  calcis,  I  added  the  antero-posterior  worm 
and  screw  of  the  extension  shoe,  which  latter  gave 
an  antero-posterior  pressure.  I  then  divided  the 
foot-plate  (with  its  retaining  side  curve)  at  a  point 
opposite  the  medio-tarsal  joint,  and  instead  of  the 
ball  and  socket  or  hinge,  I  added  an  extension  or 
traction  bar  to  the  concave  or  (in  varus)  the  inner 
side  of  the  tarsal  deformity,  with  the  centre  of 
motion  at  the  convex  or  (in  varus)  the  outer  side  of 
the  foot.  The  apparatus  is  placed  upon  the  inner 
side  of  the  foot  (in  varus),  and  the  heel  being 
retained  in  the  heel-cup  by  the  conventional  strap 
or  pad,  the  hinged  bar  and  screw  are  first  used  to 

1  Vide  New  York  Medical  Record,  November  23,  1878. 
3  Op.  cit. 


102 


MEMOIR  OF  A.  S.  ROBERTS. 


make  pressure  laterally  against  the  os  calcis.     The 
key  controlling  the  worm  and  screw  is  then  used  to 


Fig.  17. 


flex  the  foot  sufficiently  to  exert  a  slight  degree  of 
force  upon  the  gastrocnemius  muscle,  and  when  this 


Fig.  18. 


Fig.  19. 


position  is  gained  the  tarsal  traction  is  applied  by 
using  the  extension  or  traction  rod,  which,  acting 
upon  the  hinged  centre  of  motion  at  the  outer  bor- 


CLUB-FOOT:   TALIPES. 


103 


der  of  the  foot,  carries  the  anterior  part  of  the  foot 
forward,  and  direct  traction  is  exerted  upon  the 
resisting  tarsal  tissue.  In  many  severe  cases  of 
talipes  equino-varus,  the  tarsal  traction  shoe  has 
overcome  the  deformity  without  the  aid  of  ten- 
otomy." 

Fig.  20. 


Elastic  Extension.  To  Mr.  Richard  Barwell,  of 
London,  is  due  the  credit  of  first  employing  elastic 
traction  in  the  treatment  of  club-foot,  and  Dr. 
Sayre  has  popularized  it  in  this  country.  For  the 
principles  embodied  in  Barwell's  method  the  reader 
is  referred  to  the  section  on  History  and  Literature. 

The  application  of  Barwell's  dressing  has  been 
so  lucidly  explained   by  Professor  Sayre  that  we 


104  MEMOIR  OF  A.  S.  ROBERTS. 

quote  his  remarks  in  full :  "  This  consists  in  cutting 
from  stout  adhesive  plaster,  spread  on  canton-flannel, 
or  the  '  mole-skin  plaster,'  a  fan-shaped  piece.  In 
this  are  cut  several  slips  converging  toward  the 
apex  of  the  piece,  for  its  better  adaptation  to  the 
part  (see  Fig.  17).  The  apex  of  the  triangle  is 
passed  through  a  wire  loop  with  a  ring  in  the  top 
(Fig.  17),  brought  back  upon  itself,  and  secured  by 
sewing.  The  plaster  is  firmly  secured  to  the  foot 
in  such  a  manner  that  the  wire  eye  shall  be  at  a 
point  where  we  wish  to  imitate  the  insertion  of  the 
muscle,  and  that  it  shall  draw  evenly  on  all  parts  of 
the  foot  when  the  traction  is  applied.  Secure  this 
by  other  adhesive  straps  and  a  smoothly  adjusted 
roller. 

"  The  artificial  origin  of  the  muscle  is  made  as 
follows :  Cut  a  strip  of  tin  or  zinc  plate,  in  length 
about  two-thirds  that  of  the  tibia,  and  in  width 
one-fourth  the  circumference  of  the  limb  (see  Fig. 
19).  This  is  shaped  to  fit  the  limb  as  well  as  can 
be  done  conveniently.  About  an  inch  from  the 
upper  end  fasten  an  eye  of  wire.  Care  should  be 
taken  not  to  have  this  too  large,  as  it  would  not 
confine  the  rubber  to  a  fixed  point.  The  tin  is 
secured  upon  the  limb  in  the  following  manner: 
From  the  stout  plaster  above  mentioned  cut  two 
strips  long  enough  to  encircle  the  limb,  and  in  the 
middle  of  each  make  two  slits  just  large  enough  to 
admit  the  tin,  which  will  prevent  any  lateral  motion ; 
then  cut  a  strip  of  plaster,  rather  more  than  twice 
as  long  as  the  tin,  and  a  little  wider ;  apply  this 
smoothly  to  the  side  of  the  leg  on  which  traction  is 


CLUB-FOOT:   TALIPES.  105 

to  be  made,  beginning  as  high  up  as  the  tuberosity 
of  the  tibia.  Lay  upon  it  the  tin,  placing  the  upper 
end  level  with  that  of  the  plaster  (see  Fig.  20). 
Secure  this  by  passing  the  two  strips  above  men- 
tioned around  the  limb  (Fig.  21),  then  turn  the 
vertical  strip  of  plaster  upward  upon  the  tin.     A 

Fig  21. 


slit  should  be  made  in  the  plaster  where  it  passes 
over  the  eye,  in  order  that  the  latter  may  protrude. 
The  roller  should  then  be  continued  smoothly  up 
the  limb  to  the  top  of  the  tin.  The  plaster  is  again 
reversed,  and  brought  down  over  the  bandage, 
another  slip  being  made  for  the  eye,  and  the  whole 
secured  by  a  few  turns  of  the  roller.  A  small  chain, 
a  few  inches  in  length,  containing  a  dozen  or  twenty 


106  MEMOIR  OF  A.  S.  ROBERTS. 

links  for  graduating  the  adjustment,  is  then  secured 
to  the  eye  in  the  tin. 

"  Into  either  end  of  a  piece  of  ordinary  india- 
rubber  tubing,  about  one-fourth  of  an  inch  in  diam- 
eter, and  two  to  six  inches  in  length,,  hooks  of  the 
pattern  here  exhibited  (see  Fig.  18)  are  fastened  by 
a  wire  or  other  strong  ligature.  One  hook  is  fast- 
ened  to  the  wire  loop  on  the  plaster  on  the  foot,  and 
the  other  to  the  chain  above  mentioned,  the  various 
links  making  the  necessary  changes  in  the  adjust- 
ment." The  dressing  when  complete  is  shown  in 
Figs.  20  and  21. 

The  arrangement  of  Barwell's  dressing  may  be 
changed  to  suit  the  special  deformity  which  it  is 
designed  to  treat.  Sayre  states  that  the  only 
objection  which  may  be  urged  against  this  plan  of 
treatment  is  that  the  adhesive  plaster  sometimes 
slides  and  changes  its  position,  soon  becomes  worn 
out,  and  requires  frequent  readjustment,  and  will 
often  excoriate.  To  overcome  this  defect  he  has 
devised  a  club-foot  shoe,  upon  the  general  plan  of 
Scarpa's  shoe,  in  which  the  motive  power  consists 
of  elastic  bands,  and  which  can  be  resorted  to  when 
the  child  is  old  enough  to  walk.  It  is  applicable  to 
varus  and  valgus,  and  is  thus  described :  In  the 
sole,  opposite  the  medio-tarsal  articulation,  is  placed 
a  ball  and  socket,  or  universal  joint.  "  This  sole 
and  part  embracing  the  heel  consists  of  strong 
sheet  steel,  covered  with  leather  on  both  sides.  Two 
lateral  upright  bars,  B  (Fig.  22),  jointed  at  the 
ankle,  are  fastened  near  the  heel  and  to  the  collar- 
band  ;   G,  H,  and  J  arc  points  for  the  attachments 


CLUB-FOOT:   TALIPES. 


107 


tubing,  with 


of  artificial  muscles  made  of  rubber 
hooks  and  chains  at  their  ends.  To  the  inside  walls 
of  the  shoe,  near  A^  two  flaps  of  chamois  leather  are 
attached  to  lace  together,  which,  passing  over  the 
front  of  the  ankle-joint,  keep  the  heel  firmly  in  the 
back  part  of  the  shoe  "  (Say re). 


Fig.  22. 


Tenotomy  Combined  with  Extension  and  Fixation. 
In  some  cases  it  may  be  necessary,  where  they  have 
resisted  the  means  described  above,  to  resort  to 
tenotomy.  This  is  best  divided  into  two  distinct 
stages,  as  follows : 

1.  Tenotomy  of  the  tendon  of  the  anterior  tibial 
muscle  and  the  anterior  portion  of  the  internal 
lateral  ligament  (Adams),  combined  with  the  appli- 
cation of  a  lateral  varus  splint. 

2.  Division  of  the  plantar  fascia,  and  subsequent 
mechanical  extension  of  the  deep  plantar  ligaments 
(Noble    Smith),  the  extension   being  well  accom- 


108 


MEMOIR  OF  A.  S.  ROBERTS. 


plished    by   the    above-described    modification   of 
Shaffer's  varus  splint. 

Here  it  may  be  urged,  it  is  of  the  utmost  impor- 
tance that  the  strictest  care  be  exercised  after  the 
performance  of  tenotomy.  It  is  to  the  want  of 
careful  after-treatment  that  the  majority  of  the  bad 
results  and  relapses  may  be  traced,  and  tenotomy 
should  never  be  performed  where  this  necessary 
after-care  cannot  be  given. 

Fig.  23. 


Brisemeat  forcr,  a  procedure  which  has  been  at- 
tended with  considerable  success,  and  where  the 
time  at  the  disposal  of  the  surgeon  has  been  limited, 
has  been  performed  in  several  ways.     Of  these  the 


CLUB-FOOT:   TALIPES.  109 

two  most  frequent  are  that  in  which  manual  force  is 
employed,  the  patient  being  under  an  anaesthetic, 
and  that  in  which  the  force  is  applied  by  means  of 
a  powerful  instrument.  Bradford,  of  Boston,  has 
devised  such  an  instrument,  which  is  described  in 
the  "  Boston  Medical  and  Surgical  Journal "  for 
March  20,  1884,  and  is  shown  in  Fig.  23. 

Tarsotomy  and  tarsectomy,  and  their  application, 
have  already  been  alluded  to  in  the  remarks  on  the 
general  treatment  of  club-foot. 

Having  considered  in  detail  the  various  methods 
for  overcoming  the  varus  element  in  talipes  equino- 
varus,  and  before  proceeding  to  a  discussion  of  the 
means  employed  in  the  correction  of  antero-pos- 
terior  deformities,  we  may  very  properly  give  some 
consideration  to  the  normal  amount  of  flexion  and 
extension  at  the  ankle-joint.  This  has  been  sum- 
marized by  Shaffer  as  follows:  "Its  function,  except 
in  extreme  extension,  is  that  of  a  plain  hinge-joint. 
In  the  condition  we  have  to  deal  with,  flexion  and 
extension  are  the  only  movements  to  be  considered. 
Extension  of  the  foot,  in  the  adult,  is  limited  at 
about  135°,  or  45°  more  than  a  right  angle,  using 
the  long  axis  of  the  tibia  as  the  plane  of  measure- 
ment. Flexion  stops  at  about  70°,  or  20°  less  than 
a  right  angle  (see  Fig.  24).  The  position  of  the 
foot  in  standing  upon  an  even  surface,  with  the 
knee  in  full  extension,  is  about  90°.  The  amount  of 
flexion  and  extension  varies  in  different  individuals, 
but  these  figures,  based  upon  actual  experiment 
and  measurement,  represent,  I  think,  the  average  of 
normal  movement  in  the  living  adult  subject." 


110 


MEMOIR  OF  A.  S.  ROBERTS. 


Upon  this  must  be  based  our  efforts  in  the  reduc- 
tion of  these  deformities,  and  we  should  endeavor 
to  obtain  a  resultant  position  of  the  foot  as  near 
normal  as  possible :  thus,  in  talipes  equinus  the 
aim  should  be  to  make  it  possible  for  the  foot  to 
describe  an  arc  which  will  end  in  the  position  shown 
in  the  figure  as  70°,  and  in  calcaneus  extension 
should  be  possible  until  the  normal  position  marked 
135°  is  attained. 

Fig.  24. 


Various  degrees  of  normal  flexion  and  extension  at  the  ankle-joint. 
(Shaffer's  modification  of  Noble  Smith's  scheme.) 

The  means  at  our  disposal  for  the  accomplishment 
of  this,  are : 


CLUB-FOOT:   TALIPES.  HI 

1.  Manipulation,  Massage,  and  Electricity.  These 
have  the  same  function  in  the  anteroposterior  de- 
formity as  was  described  in  speaking  of  the  varus 
element.  It  is  only  in  the  application  of  these  forces 
that  the  difference  exists.  Here  manipulations,  etc., 
should  be  directed  to  those  muscles  and  tendons 
producing  the  equinus,  the  application  of  the  forces 
mentioned  having  for  their  object  the  conversion  of 
the  equinus  into  a  calcaneus  position. 

2.  Hetentive  dressings  have  been  so  thoroughly 
described  when  speaking  of  varus,  that  it  is  not 
necessary  to  repeat  the  description  here.  All  the 
articles  there  mentioned  for  the  construction  of  sim- 
ple splint  may  be  used  with  advantage  in  equinus, 
both  before  and  after  tenotomy. 

3.  Extension  and  Eixation.  The  ordinary  forms 
of  apparatus  used  to  accomplish  extension  and  fixa- 
tion consist  essentially  of  two  uprights  running 
parallel,  and  placed  on  either  side  of  the  leg,  con- 
nected by  a  band  to  surround  the  calf;  a  joint  cor- 
responding to  the  ankle ;  a  heel-cup  with  a  strap 
and  pad  to  secure  the  os  calcis ;  and  a  sole-plate, 
with  or  without  a  hinge,  to  correspond  with  the 
medio-tarsal  joint.  This,  which  is  the  usual  modi- 
fication of  Scarpa's  shoe,  is  made  the  means  for  the 
application  of  force  intended  to  act  in  place  of  the 
anterior  and  lateral  muscles.  The  objection  to  the 
ordinary  forms  of  apparatus  used  for  the  correction 
of  antero-posterior  deformities  has  led  Newton  M. 
Shaffer,  of  New  York,  to  criticise  them  as  follows : 
"  It  seems  very  easy  to  construct  an  apparatus  with 
a  joint   to   correspond  with   the   tibio-astragaloid 


112  MEMOIR  OF  A.  S.  ROBERTS. 

articulation,  and  to  make  this  joint  the  centre  of  an 
artificial  movement  imparted  to  the  anterior  part  of 
the  foot  through  the  medium  of  the  foot-plate.  But 
let  us  see  what  happens  when  we  attempt  to  do  this 
with  the  ordinary  forms  of  apparatus.  The  centre 
of  motion,  so  far  as  the  equinus  position  is  con- 
cerned, is  at  the  tibio-astragaloid  articulation.  The 
resistance  lies  in  the  post-tibial  muscles,  and  the 
power  is  applied  in  front  to  the  tarsus  and  metatar- 
sus— the  object  being  simply  to  flex  the  foot  and 
bring  down  the  heel.  As  the  anterior  part  of  the 
foot  rotates  upon  its  artificial  ankle-joint  centre,  or, 
to  put  it  in  other  words,  as  we  crowd  the  os  calcis 
into  the  heel-cup,  and  attempt  to  flex  the  foot  in 
very  much  the  same  manner  we  would  shut  the  half- 
opened  blade  of  a  knife — the  heel,  unless  restrained, 
slips  forward.  The  attempt  is  made  to  control  this 
movement  by  tying  the  heel  down  to  the  foot-plate 
and  in  the  heel-cup,  with  the  heel-strap.  If,  after 
this  heel-strap  (the  analogue  of  the  anterior  annular 
ligament)  is  tied,  a  considerable  pressure  be  applied 
in  the  direction  of  flexion  (even  in  many  cases  after 
tenotomy),  the  further  tendency  of  the  heel  (being 
restrained  in  front  by  the  heel-strap)  is  to  slip  up- 
ward and  backward  away  from  this  artificial  annular 
ligament,  ultimately,  in  many  cases,  resting  on  the 
top  of  the  heel-plate,  which  forms  the  cup.  When 
this  occurs,  all  control  over  the  foot  is  lost,  as  it 
turns  toward  that  side  upon  which  the  contractions 
exist.  One  of  the  direct  effects  of  mechanical 
flexion,  as  applied  in  the  customary  forms  of  ap- 
paratus,  to    overcome    either  a    post-tibial    or    a 


CLUB-FOOT:   TALIPES.  113 

plantar  contraction,  is  to   crowd  the  tarsal  bones 
together. 

"  The  foot-plate  rotates  around  an  axis,  the  centre 
of  which  is  the  '  ankle-joint '  of  the  apparatus.  The 
point  at  which  the  retaining  force  and  counter- 
pressure  (under  the  heel-strap),  which  holds  the  foot 
in  the  apparatus,  is  made,  must  also  rotate  around 
the  pivotal  point.  Upon  this  heel-strap  we  must 
rely  principally  for  the  means  of  retaining  the  foot 
in  the  apparatus,  and  it  supplies  the  only  important 
means  for  regulating  the  relation  of  the  anatomical 
to  the  artificial  centre.  If  the  foot,  as  a  whole,  could 
be  secured  perfectly  in  the  apparatus,  and  be  made, 
as  we  apply  a  gradually  increasing  force,  to  mechan- 
ically follow  the  direction  imparted  to  it  by  the  arti- 
ficial mechanism,  the  trouble  would  be  reduced  to 
the  minimum.  Our  artificial  would  then  correspond 
to  the  human  mechanism.  But,  principally  through 
the  causes  referred  to,  the  centre  of  rotation  in  the 
foot  and  in  the  apparatus  become  changed  in  their 
relations  to  each  other,  and  all  the  pressure  exerted 
under  these  circumstances  is  productive  of  injury. 
As  pointed  out,  the  tarsal  bones  become  crowded 
together,  the  heel  slips  beyond  the  control  of  the 
apparatus,  exposed  points  are  apt  to  become  ex- 
coriated, and  the  result,  while  sufficient  force  has 
been  employed,  though  misapplied,  is  very  discour- 
aging in  very  many  instances." 

In  view  of  the  justice  of  these  criticisms,  and  to 
overcome  these  faults,  Shaffer  has  devised  an  im- 
proved extension  club-foot  shoe,  a  modification  of 
Scarpa's  shoe,  which  presents  nothing  novel  with 

8 


114 


MEMOIR  OF  A.  S.  ROBERTS. 


the  exception  of  an  extension-bar  acting  upon  the 
sole  of  the  brace. 

The  club-foot  extension  apparatus  (Fig.  25)  con- 
sists of  the  ordinary  uprights  fastened  to  the  heel- 


Fig.  25. 


Extension  equinus  brace,  adjusted  to  deformity. 

piece  by  a  plain  joint  on  one  side,  and  an  endless 
screw,  A,  on  the  other.  This  screw  allows  us,  by 
using  a  key,  to  place  the  foot-piece  of  the  apparatus, 
as  a  whole,  in  any  antero-posterior  position  we 
choose,  and  to  alter  it  at  will,  either  before  or  after 
application  to  the  foot.     That  part  of  the  foot-piece 


CLUB-FOOT:   TALIPES. 


115 


which  corresponds  with  the  tarsus  and  metatarsus 
is  joined  by  a  common  extension-rod,  c,  to  the  por- 
tion which  lies  under  the  os  calcis.  With  a  key  we 
are  enabled  to  extend  the  anterior  part  of  the  foot- 
piece  at  pleasure. 

To  apply  this  instrument,  we  first,  by  means  of 
the  key,  place  the  foot-piece  in  a  position  that  will 


Fig.  26. 


Extension  equinus  brace ;  first  stage  of  correction. 

exactly  correspond  with  the  antero-posterior  position 
of  the  foot  (whether  tenotomy  has  been  performed 
or  not).  We  then  secure  the  heel  by  tying  the  heel- 
strap,  d,  and  by  means  of  another  Avebbing-strap,  e, 
passing  over  the  tendo  Achillis,  immediately  above 


116  MEMOIR  OF  A.  S.  ROBERTS. 

its  insertion  into  the  os  calcis,  secure  it  to  the  ante- 
rior or  extension  portion  of  the  foot-piece  by  buckles 
on  either  side,  as  shown  in  the  figure.     The  key,  at 

b,  is  now  used  to  flex  the  foot,  in  overcoming  to  the 
desired  extent  the  tendo  Achillis  resistance.  "  When 
this  shall  have  been  accomplished  it  will  be  found, 
as  in  all  similar  apparatus  where  the  artificial  flexion 
alone  is  depended  on  to  overcome  the  post-tibial 
resistance,  that  the  posterior  aspect  of  the  heel  is 
pressing  against  the  heel-plate  "  (see  Fig.  26).  In 
varus  the  cuboid,  in  valgus  the  scaphoid  bone,  be- 
comes uselessly  crowded,  and  in  a  direction  which 
does  little  or  no  good.  All  the  tarsal  bones  are 
also  crowded  together  by  the  force  which  is  acting 
in  the  arc  of  a  circle,  the  centre  of  which  is  the 
ankle-joint.     But  now,  a  turn  or  two  of  the  key,  at 

c,  brings  the  foot  under  control,  and  the  centre  of 
motion  being  thus  transferred,  the  heel  must  neces- 
sarily describe  an  arc  whose  centre  is  at  the  point 
of  resistance,  d,  and  is  thus  brought  firmly  into  the 
heel-cup,  and  if  the  extension  force  be  further  ap- 
plied, will  rest  squarely  upon  the  extension-bar, 
thereby  securing  flexion  at  the  ankle  corresponding 
to  the  degree  of  flexion  of  the  foot-piece  of  the 
brace,  as  shown  in  Fig.  27.  If  the  tarsal  de- 
formity be  only  slight,  the  pressure  at  the  cuboid 
or  scaphoid  is  modified ;  the  compression  of  the 
tarsus  is  relieved;  the  plantar  fascia,  the  plantar 
muscles,  and  the  tarsal  ligaments  are  actually 
stretched;  besides  which,  the  os  calcis  is  placed 
tinder  restraint;  in  this  way  the  traction  force 
passes  through  the  tarsus  directty  to  the   tendo 


CLUB-FOOT:   TALIPES. 


117 


Achillis.  The  mechanical  counter-extension,  of 
course,  is  at  the  heel-strap,  d.  It  simply  retains 
the  foot  in  a  position  that  allows  a  certain  amount 
of  force  to  be  expended  on  the  contracted  tissues. 
The  greater  pressure  under  the  heel-strap,  however, 
is  exerted  by  flexing  the  foot  with  key  b,  rather 

Fig.  27. 


Extension  equinus  brace  ;  complete  correction. 


than  by  using  the  extension  at  c.  Particular  pains, 
however,  should  be  taken  not  to  make  these  com- 
bined forces  too  great.  "  As  a  matter  of  precaution 
I  always  place  several  thicknesses  of  sheet-lint  or 
a  thick  layer  of  absorbent  cotton  (this  latter  makes 
an  excellent  elastic  pad)  under  the  heel-strap  and 


118  MEMOIR  OF  A.  S.  ROBERTS. 

at  the  sides  of  the  heel-cup.  If  a  very  considerable 
extension  is  necessary,  I  pass  an  additional  padded 
strap  over  the  lower  end  of  the  tibia,  passing  the 
tapes  attached  back  of  the  two  uprights,  securing 
them  in  front  over  the  pad.  It  is  a  matter  of  sur- 
prise to  me  how  well,  with  a  little  care,  pressure  is 
tolerated  at  this  exposed  point  under  the  heel-strap, 
and,  also,  how  little  traction,  applied  in  the  manner 
indicated,  through  the  tarsus,  is  necessary  to  accom- 
plish the  object."  In  order  to  inspect  the  part 
exposed  to  pressure  without  removing  the  appa- 
ratus, it  is  only  necessary  to  loosen  the  heel-strap 
and  turn  key  c  until  the  extension-rod  drops  from 
the  cylinder,  when  the  entire  posterior  part  of  the 
apparatus  may  be  easily  removed.  "  The  part  under 
the  heel-pad  should  be  inspected  once  a  day.  An 
important  point  may  be  mentioned  here :  it  is  always 
well  to  overcome  almost  wholly  the  lateral  malposi- 
tion of  the  tarsus  before  applying  direct  traction. 
Time  will  be  saved,  and  some  annoyance  also,  if 
this  rule  be  uniformly  followed." 

The  force  which  may  be  exerted  by  the  above 
apparatus  should  not  be  applied  continuously,  as 
is  popularly  supposed.  On  the  contrary,  it  should 
be  used  as  an  intermittent  force,  and  at  stated 
intervals. 

In  order  to  maintain  the  position  gained  by  the 
extension  as  used  above,  it  is  well  to  place  the  foot 
in  ;i  retention  shoe  whilst  the  patient  sleeps.  The 
same  apparatus  may  be  used  when  the  foot  has  been 
brought  to  a  right  angle,  where  it  can  be  secured  by 
means  of  a  stop-joint  (see  Fig.  28). 


CLUB-FOOT:   TALIPES. 


119 


Should  the  above  extension  and  fixation  apparatus 
be  unobtainable,  good  results  are  often  secured  by 
the  use  of  the  means  described  under  the  head  of 


Retentive  Dressings. 


Fig.  28. 


Retention  equinus  shoe. 


4.  Elastic  extension  has  already  been  spoken  of  in 
detail  when  discussing  the  treatment  of  the  lateral 
deformity.  The  methods  of  Barwell  and  Sayre,  so 
adapted  as  to  meet  the  antero-posterior  deformity, 
as  shown  in  Figs.  20,  21,  and  22,  describe  the  appa- 
ratus used  by  them. 


120  MEMOIR  OF  A.  S.  ROBERTS. 

5.  Tenotomy,  combined  with  extension  and  fixation, 
will  comprise  the  division  of  the  tendo  Achillis,  with 
the  necessary  after-treatment,  this  completing  the 
third  stage  in  the  treatment  of  the  compound  form, 
talipes  equino-varus.  No  especial  description  is 
required  for  the  division  of  the  tendo  Achillis,  and 
the  after-treatment  has  been  discussed  under  the 
general  consideration  of  tenotomy. 

Two  conditions  may  be  alluded  to  before  closing 
this  section. 

First :  Symptomatic  or  compensatory  equinus,  a 
condition  found  after  shortening  of  the  leg  from 
whatever  cause,  the  patient  attempting  to  equalize 
length  of  the  extremity  affected  by  standing  upon 
the  ball  of  the  foot.  This  is  easily  corrected  by  the 
addition  of  a  high  sole  or  patten. 

Second :  A  condition  of  "residual "  varus.  Often, 
even  after  the  foot  has  been  brought  into  excellent 
position,  a  slight  inversion  of  the  anterior  part  of 
the  foot  remains.  This  is  often  due  to  a  relaxed 
condition  of  the  hip-  and  knee-joints,  allowing  of 
abnormal  inward  rotation  of  the  foot.  To  correct 
this,  many  forms  of  apparatus  have  been  devised. 
Those  of  Gregory  Doyle,  or  Stillman's  modification 
(see  Fig.  29),  as  also  those  of  Dr.  Sayre  and  Dr. 
Stedman,  afford  the  best  means  at  our  disposal  for 
overcoming  this  condition. 

Talipes  Equino-valgus.  The  principles  of  the 
treatment  of  club-foot  having  been  fully  discussed 
under  the  caption  Talipes  Equino-varus,  it  is  only 
necessary  here  to  speak  of  the  modification  of 
methods  caused  by  the  difference  in  the  direction  of 


CLUB-FOOT:   TALIPES. 


121 


the  deformity,  and  the  tissues  involved.  Owing  to 
its  extreme  rarity  the  surgeon  is  seldom  called  upon 
to  treat  cases  of  this  kind ;  but  here,  as  in  talipes 
equino-varus,  it  is  necessary  to  overcome  the  ele- 


FlG.  29. 


Stillman's  modification  of  Gregory  Doyle's  spiral  spring 
apparatus  for  residual  varus. 


ment  of  valgus  first,  which  may  be  accomplished 
by  means  similar  to  those  mentioned  when  speaking 
of  equino-varus,  the  extension  force,  however,  being 
applied  to  the  contracted  peronei  group ;  after  the 
reduction  of  the  lateral  deformity,  the  equinus  is 


122  MEMOIR  OF  A.  S.  ROBERTS. 

overcome  by  the  same  means  as  serve  to  correct 
the  same  deformity  coexisting  with  varus.  Mas- 
sage, electricity,  and  the  other  adjuvants  heretofore 
mentioned  should  all  be  used  in  the  manner  already 
described. 

Similar  methods  will  apply  to  Talipes  Calcaneo- 
varus  and  valgus.  When  speaking  of  Talipes  Cal- 
caneus, the  means  for  the  correction  of  the  deformity 
were  fully  discussed,  and  attention  was  called  to  the 
application  of  rubber  muscles  posteriorly,  and  to 
excision  and  suture  of  a  portion  of  the  tendo  Achil- 
lis.  Reference  to  this  portion  of  the  article  will  fur- 
nish details  of  these  methods  ;  the  lateral  deformity 
will,  of  course,  require  the  same  methods  of  treat- 
ment as  are  called  for  by  similar  lateral  deviations 
occurring  in  the  compound  forms  already  described. 

For  the  works  which  have  been  consulted  in  the 
preparation  of  this  article  the  reader  is  referred  to 
the  section  on  History  and  Literature. 


POTT'S    DISEASE 


POTT'S   DISEASE. 


DefhstitiojST.  Pott's  disease  of  the  spine,  so 
called  from  the  accurate,  although  not  the  first, 
description  of  caries  of  the  vertebrae,  by  Percival 
Pott  in  1779,  is  a  lesion  of  the  vertebral  bodies  or 
intervertebral  disks,  characterized  by  inflammatory 
changes,  progressive  in  character,  and  ending  in 
total  or  partial  destruction  of  the  parts  involved, 
usually  terminating  in  anchylosis  more  or  less  com- 
plete, with  the  characteristic  posterior  deformity. 

Synonyms .  Posterior  curvature,  angular  curva- 
ture, spinal  arthritis  or  osteitis ;  Greek,  Kyphosis  ; 
French,  Mal-de-Pott,  Cyphose;  German,  Spitz- 
huckel.  The  objection  to  most  of  these  terms  is 
that  they  express  either  a  pathological  condition  or 
a  result  of  the  disease,  in  no  wise  making  clear  or 
improving  the  conception  of  the  trouble.  It  would 
thus  seem  well  to  retain  the  commonly-accepted 
name  of  Pott's  disease.  If  any  scientific  term  were 
to  be  adopted,  Spondylitis  avouM  be  the  least  open 
to  objection. 

ETIOLOGY. 

Pott's  disease  is  essentially  a  disease  of  child- 
hood, although  not  entirely  limited  to  this  period  of 
life,  it  having  been  found  in  the  fetus,  in  extreme 


12G  MEMOIR  OF  A.  S.  ROBERTS. 

infancy,  in  middle  age,  and  in  very  old  people.  As 
a  rule,  however,  it  is  most  often  found  between  the 
ages  of  three  and  fourteen  years.  Sex  exerts  no 
special  influence  in  its  production,  although  those 
who  believe  only  in  the  traumatic  origin  of  the  dis- 
ease speak  of  its  more  frequent  occurrence  in  males, 
from  their  presumed  greater  liability  to  injuries. 

In  a  general  consideration  of  the  etiology  of  Pott's 
disease  it  will  be  well  to  divide  the  subject  into — 

1.  Exciting  causes — traumatisms  and  fevers. 

2.  Diathetic  causes — tubercle,  scrofula,  rheuma- 
tism, syphilis,  etc. 

Excitixg-  Causes.  In  the  question  of  causation 
of  Pott's  disease,  injury  occupies  so  important  a 
place  in  the  minds  of  both  the  profession  and  the 
laity  that  a  brief  discussion  of  its  significance  as  a 
causative  factor  may  not  be  amiss  in  this  connection. 

In  almost  all  cases  presented  for  examination,  the 
information  is  usually  volunteered  that  the  patient 
has  received  a  blow  or  a  fall.  A  more  careful  ques- 
tioning elicits,  as  a  rule,  a  very  vague  etiological 
description  of  the  traumatism.  Thus  it  often  hap- 
pens that  in  a  child  presenting  a  marked  deformity 
the  traumatism  assigned  as  its  cause  is  referred  to 
a  very  recent  period  and  is  in  character  entirely  out 
of  proportion  to  the  supposed  result.  There  can  be 
no  doubt  that,  in  the  majority  of  cases  presenting 
clinically,  the  relations  of  cause  and  effect,  consid- 
ered from  the  stand-point  of  injury,  are  such  as  in 
no  wise  to  account  for  the  symptoms  presented.  If 
it  should  be  accepted  that  the  most  frequent  causes 
of  Pott's  disease  are  concussions    and    blows,  as 


POTTS  DISEASE.  127 

urged  by  the  traumatists,  it  would  follow  that  many 
thousands  of  children  in  daily  receipt  of  such  in- 
juries would  be  the  victims  of  this  disease  or  of 
some  analogous  joint-trouble.  That  this  is  not  the 
fact  is  proved  by  the  comparative  infrequency  of 
the  disease  in  question.  Again,  the  amount  and 
character  of  injury  are  important  considerations. 
Thus,  in  many  children  a  very  slight  traumatism 
has  been  given  as  the  cause  of  the  subsequent 
trouble,  and  in  many  cases,  if  no  other  conditions 
were  present,  might  be  accepted  as  a  definite  cause. 
Against  these  may  be  placed  the  severe  injuries 
and  falls  received  in  childhood,  terminating  in  a 
short  time  in  perfect  recovery  or  in  death.  From 
this  it  follows  that  in  the  one  case  there  must  be 
some  special  or  underlying  condition  predisposing 
to  the  production  of  a  chronic  insidious  disease, 
while  in  the  other  case  the  healthy  organism  so 
modifies  the  process  that  a  different  result  is  brought 
about. 

The  fact  of  the  matter,  as  it  appears  to  me,  is  that 
injury,  considered  purely  as  a  primary  determining- 
cause,  has  no  claims  to  special  consideration  in  the 
large  majority  of  cases ;  that  Pott's  disease  often 
develops  without  any  history  of  such  injury  as 
would  show  a  conclusive  connection  between  the 
injury  and  the  disease ;  and  that  at  best  it  is  but  the 
exciting  cause  bringing  into  activity  an  underlying- 
general  condition,  and  manifested  by  its  local  ex- 
pression at  the  site  of  the  supposed  traumatism. 

Among  the  causes  of  caries  of  the  spine  which 
stand  in  the  relation  of  direct  exciting  agents,  the 


128  MEMOIR  OF  A.  S.  ROBERTS. 

continued  fevers  of  childhood,  measles,  scarlatina, 
etc.,  and  in  fact  all  depressing  conditions  lowering 
the  vitality,  are  prominent  and  direct  etiological 
factors.  The  same  underlying  condition  described 
as  giving  potency  to  injury  is  undoubtedly  often 
present,  the  difference  in  the  traumatism  being 
simply  one  of  character  and  degree.  The  influence 
of  a  depressing  poison  on  a  tender  developing  bone 
is  none  the  less  on  account  of  this  difference  in 
causation,  although  manifest  often  in  a  different 
manner. 

Diathetic  Causes.  Our  knowledge  of  scrofula 
and  tubercle  in  their  causal  relations  to  Pott's  dis- 
ease is  as  yet  not  of  that  definite  character  which  is 
desirable,  and  therefore  cannot  receive  more  than  a 
passing  notice.  When  we  speak  of  scrofula  refer- 
ence is  had  rather  to  a  state  or  vulnerable  condition 
of  the  tissues  than  to  a  complete  pathological  entity. 
Scrofula,  therefore,  we  would  refer  to  as  a  condition 
of  the  system  rendering  it  peculiarly  prone  to  chronic 
inflammations  of  a  low  type,  retrogressive  in  char- 
acter, and  often  occurring] without  adequate  cause, 
accompanied  by  certain  marked  tendencies  to  skin- 
affections,  glandular  enlargements,  and  bone-disease. 

Tubercle  at  the  present  day  plays  so  important  a 
role  in  its  etiological  relation  to  bone-inflammations 
of  the  chronic  type,  and  is  of  such  consequence, 
that  a  detailed  discussion  would  hardly  be  in  place 
here.  For  a  complete  description  the  reader  is  re- 
ferred to  the  article  on  tuberculosis,  in  another 
section  of  this  work. 

Syphilis  and  rheumatism  may  at  times  be  diathetic 


POTT'S  DISEASE.  129 

conditions  productive  of  Pott's  disease,  but  as  yet 
no  direct  evidences  have  been  collected  concerning 
these  conditions  and  their  manifestations  in  the 
malady  under  discussion. 

PATHOLOGY. 

Pathologically  it  may  be  well  here  to  regard  the 
lesions  found  in  Pott's  disease  as  identical  with  the 
changes  found  in  other  bone  structures  in  which 
there  is  tubercular  caries.  This  is  destructive  in 
character,  and  may  be  confined  to  a  single  vertebra 
or  may  involve  several.     (Pig.  30.) 

Fig.  30. 


Showing  extensive  erosion  of  clorso-lumbar  vertebrae. 

It  is  in  many  cases  attended  or  limited  by  the 
occurrence  of  a  rarefying  osteitis.  In  the  strumous 
form  of  rarefying  osteitis  the  first  step  in  the  pro- 

9 


130  MEMOIR  OF  A.  S.  ROBERTS. 

cess  of  inflammation  is  that  of  congestion,  the  bone 
appearing  as  if  blood  were  extravasated  throughout 
its  structure;  secondly,  there  is  the  formation  of 
granulation-tissue ;  and  lastly  there  occurs  a  degen- 
eration and  softening  of  the  new  formations,  with 
purulent  exudations  and  absorption  of  bone-tra- 
becula?.  JSTow  the  bone-corpuscles  undergo  fatty 
degeneration,   and    are    presently    destroyed,   and, 


i 


Erosion  of  lumbar  spine,  popliteal  abscess,  without  deformity. 

owing  to  strangulation  of  the  vessels,  caseation  of 
the  inflammatory  products  results.  When  the  dis- 
ease is  rapid  the  cancellous  spaces  and  Haversian 
canals  are  filled  with  pus.  The  process,  being  a 
strumous  or  tubercular  one,  differs  from  simple 
traumatic  rarefying  osteitis,  arising,  as  it  does,  from 


POTT'S  DISEASE. 


131 


an  internal  or  constitutional  cause,  or  from  such 
local  irritation  that  a  slight  injury  would  bring  it 
into  activity.  Even  such  injury  is  not  necessary  to 
provoke  this  strumous  or  tubercular  caries,  it  often 
arising  from  no  appreciable  cause.  A  peculiar 
feature  of  this  caries  is  its  limitation  to  spongy 
bone-tissue,  it  rarely  affecting  the  transverse,  artic- 
ular, or  spinous  processes  primarily.     (Fig.  31.) 


Fig.  32. 


Characteristic  "  hunchback  "  deformity. 


Again,  this  degenerative  process  assumes  different 
degrees  of  intensity,  being  in  some  cases  superficial, 
involving  only  a  portion  of  the  anterior  surfaces  of 
the  vertebrae,  while  in  other  cases  it  not  only  exca- 
vates the  body  of  the  vertebra?,  but  also  attacks  the 


132  MEMOIR  OF  A.  S.  ROBERTS. 

intervertebral  fibro-cartilages  and  the  adjacent  soft 
parts,  giving  rise  to  abscess.  (Fig.  32.)  Not 
infrequently  the  abscess  is  confined  within  the  bone, 
the  exudation  becoming  purulent,  the  granulation- 
tissue  breaking  down,  the  pus  and  debris  collecting 
into  an  abscess-cavity,  and  the  walls  of  the  abscess 
being  composed  of  the  inflamed  disintegrating  bone 
and  lined  by  caseous  pus. 

It  oftener  happens  that  in  rarefying  osteitis  the 
bone  is  absorbed  in  such  a  manner  that  an  island  of 

Fig.  33. 


&t 


(■■■; 


l&. 


Marked  angular  curvature,  resulting  in  compression,  myelitis, 
and  paraplegia. 


osseous  substance  is  separated  from  the  rest  by  a 
belt  of  granulation-tissue  and  dies,  giving  rise  to 
the  caries  necrotica,  but  if  it  retains  its  vascular 
connection  it  forms  a  living  sequestrum.     While 


POTT'S  DISEASE.  133 

the  bodies  of  the  vertebrae  are  being  absorbed,  osteo- 
plastic or  protective  osteitis  takes  place  about  the 
neural  arches,  being  a  conservative  action,  prevent- 
ing by  sudden  dislocation  a  crushing  of  the  spinal 
cord.     (Fig.  33.) 

A  class  of  cases  were  first  described  by  Brodie 
in  which  no  suppuration  took  place,  and  these  have 
at  a  more  recent  period  been  designated  as  dry 
caries,  or  caries  sicca.  They  are  identical  with  the 
so-called  "  osteitis  fungosa "  (Billroth),  and  are 
characterized  by  the  presence  of  interstitial  granu- 
lation-tissue growing  throughout  the  bone.  Here 
the  granulation-tissue  fills  the  Haversian  canals  and 
medullary  spaces,  and  insidiously  eats  its  way  into 
the  bony  meshes.  In  this  class  of  cases  the  granu- 
lation-tissue may  undergo  fatty  degeneration  and 
caseation  without  suppuration. 

It  will  be  readily  seen  that  the  foregoing  condi- 
tion differs  widely  from  the  simple  rarefying  osteitis, 
or  caries,  the  result  of  injury,  there  being  in  the 
latter  no  underlying  vice  of  the  system.  In  this 
class  of  cases  we  have  first  a  simple  dilatation  of 
the  bloodvessels,  followed  by  a  pouring  out  of  liquor 
sanguinis  and  leucocytes.  In  many  cases  the  pro- 
cess stops  at  this  point,  and,  the  inflammation  sub- 
siding, resolution  takes  place,  the  parts  returning  to 
their  normal  contour.  This  limited  caries  undoubt- 
edly explains  the  rapid  recovery  of  many  cases  of 
so-called  spondylitis  following  traumatism,  and  may 
also  happen  when  Pott's  disease  follows  one  of  the 
exanthemata,  the  patient  being  of  sound  constitu- 
tion at  the  time. 


134  MEMOIR  OF  A.  S.  ROBERTS. 

SYMPTOMATOLOGY. 

Before  attempting  to  enter  into  a  complete  de- 
scription of  the  symptoms  as  met  with  in  the 
different  regions  of  the  spine  in  a  case  of  Pott's 
disease,  some  general  consideration  of  the  different 
stages  is  of  importance,  and  of  these  we  will  begin 
with  the  stage  of  invasion. 

In  the  vast  majority  of  cases  the  general  health 
of  the  patient  has  been  for  a  greater  or  less  time 
below  the  normal  standard.  Even  without  any 
tubercular  or  strumous  history  or  appearance  that 
is  marked,  there  is  a  condition  present  best  expressed 
by  the  comprehensive  term  malaise.  A  child  shows 
indifference  to  its  surroundings,  its  usual  occupa- 
tions or  enjoyments,  and  presents  a  listless,  dejected 
appearance.  It  is  easily  tired  and  irritable,  and 
appears  sick.  The  appetite,  previously  good,  be- 
comes affected ;  the  child  loses  flesh,  and  the  skin 
assumes  an  appearance  very  different  from  the  clear 
look  of  perfect  health.  The  muscular  tissues  often 
become  flabby,  and  the  total  appearance  of  the 
patient  indicates  that  it  is  affected  by  some  insidious 
potent  malady. 

Here  we  have  the  condition  met  with  in  many 
bone-diseases,  especially  where  the  epiphyses  are 
principally  affected,  the  so-called  "  incipient  stage," 
or,  as  it  has  been  otherwise  designated,  the  "  pre- 
t  nbercular  "  or  "  vulnerable  "  condition.  This  stage 
often  escapes  detection,  the  symptoms  rarely  being 
connected  with  the  disease,  and  their  importance 
being  frequently  overlooked.     These  symptoms  in- 


POTT'S  DISEASE.  135 

dicate  the  existence  of  a  period,  and  their  correct 
interpretation  at  this  time  is  of  the  utmost  impor- 
tance as  regards  the  ultimate  result  of  the  case,  this 
being  the  most  favorable  time  to  avert  an  increase 
of  inflammation  and  prevent  deformity. 

Stage  of  Paiist.  Succeeding  the  rather  general 
disturbance  just  described,  we  come  to  a  period  the 
most  important  symptom  of  which  is  pain.  The 
pain  of  Pott's  disease  varies  greatly  in  character 
and  extent,  and  its  location  is  always  dependent  on 
the  site  of  the  inflammation. 

It  will  be  well  in  this  connection  to  say  a  few 
words  regarding  the  commonly-accepted  idea  that 
the  pain  of  caries  of  the  spine  is  always  to  be  found 
posteriorly  localized  at  the  seat  of  the  disease  as 
manifested  by  the  deformity.  Much  importance 
in  making  an  examination  of  the  spine  has  been 
attached  to  the  recognition  of  this  local  pain,  by 
means  of  hot  sponges  and  other  substances  passed 
along  the  spinal  column.  Nothing  could  be  more 
fallacious,  experience  showing  that  the  pain  of  Pott's 
disease  is  referred  to  the  posterior  portion  of  the  spine 
only  in  very  rare  instances. 

The  pain  of  Pott's  disease  is,  as  a  rule,  subacute, 
varying  greatly  in  character  and  in  degree,  in  many 
cases  being  intermittent,  at  other  times  being  de- 
scribed as  lancinating  and  intense.  There  is  a 
marked  relation  between  the  rapidity  and  extent  of 
the  inflammation  and  the  amount  of  pain.  Its  loca- 
tion may  be  tersely  stated  as  following  the  general 
law  that  pain  which  is  the  result  of  nerve-irritation 
is  reflected  to  its  periphery.    Thus,  it  ic  often  found 


136  MEMOIR  OF  A.  S.  ROBERTS. 

below  the  seat  of  the  disease  and  anteriorly  (gas- 
tralgia),  but  rarely  above  it,  the  exception  occurring 
in  some  cases  of  cervical  caries.  As  a  rule,  the  pain 
is  worse  in  the  earlier  stages  and  at  night,  and  is 
aggravated  by  motion  and  position.  Cases  have 
been  recorded,  however,  where  pain  has  been  entirely 
absent  through  the  whole  course  of  the  disease. 

Stage  of  Muscular  Rigidity.  We  next  meet 
with  a  condition  of  the  muscles  which  is  of  impor- 
tance in  both  diagnosis  and  prognosis.  This  is  a 
state  of  spasm  or  rigidity,  and  is  supposed  to  be 
due  to  reflex  irritation  of  the  nerves  supplying  the 
diseased  bone.  Its  presence  is  regarded  as  pathog- 
nomonic of  osteitis.  Here,  as  in  all  the  large  artic- 
ulations, where  the  condition  of  the  muscles  is 
constantly  found  associated  with  joint  disease,  its 
function  would  seem  to  be  an  attempt  to  mobilize 
the  part,  and  is  nature's  effort  to  bring  about  this 
end.  It  is  an  early  sign,  sometimes  appearing  even 
before  pain  is  complained  of,  and  continues  to  a  very 
late  stage  of  the  disease.  This  constitutes  at  times 
the  only  available  symptom,  and  is  at  all  times  of 
the  greatest  practical  importance  in  diagnosis  when 
properly  interpreted.  It  is  not  to  be  confounded 
with  the  bony  rigidity  found  at  a  late  period  of  the 
malady,  the  result  of  partial  or  complete  anchylosis. 
This  reflex  muscular  spasm  is  unique  in  character, 
and  its  study  in  connection  with  chronic  bone  dis- 
ease shows  peculiarities  not  found  in  other  condi- 
tions. It  is  an  unyielding  tetanoid  spasm,  present 
day  and  night,  being,  so  to  speak,  forever  on  guard 
to  prevent  any  injury  to  the  diseased  part.     It  yields 


POTT'S  DISEASE.  137 

only  to  complete  anaesthesia,  ordinary  doses  of  opium 
or  chloral  not  affecting  it.  Accompanying  this 
spastic  condition  of  the  muscles,  the  result  of  nerve 
irritation,  we  also  have  a  specific  atrophy,  reflex  in 
character,  and  noticeable  at  times  in  Pott's  disease 
where  the  mnscles  are  well  developed,  especially  in 
the  erector  spinae  group,  and  progressing  in  direct 
ratio  as  the  disease  advances.  This  symptom  is 
not  always  so  easy  to  determine  in  Pott's  disease 
as  in  other  articulations,  located  more  specifically, 
but  is  undoubtedly  always  present. 

Stag-e  of  Deformity.  Although,  rationally 
considered,  the  deformity  of  spondylitis  takes  place 
at  a  later  period  than  the  stages  already  mentioned, 
it  is  by  no  means  unusual,  especially  in  public  prac- 
tice, for  it  to  be  the  first  symptom  of  sufficient 
importance  to  attract  the  attention  of  the  parents 
or  friends  to  the  patient,  or  deemed  worthy  of  the 
care  of  the  surgeon.  This  projection  backward  of 
one  or  more  spinous  processes  is  identical  with  that 
period  already  mentioned  when  speaking  of  pathol- 
ogy, where  there  is  a  breaking  down  of  the  vertebral 
bodies  forming  the  anterior  support  of  the  spine. 
The  superincumbent  weight  falling  on  the  weakened 
support  increases  the  projection,  causes  abnormal 
pressure  on  the  carious  and  weakened  vertebrae  in 
their  changed  direction,  and  alters  the  normal  curves 
of  the  spinal  column.  Where  the  carious  process 
is  rapid  and  extensive,  the  amount  of  deformity 
will  be  proportionately  large,  and  sharp  or  gradual, 
according  to  the  amount  of  disease  present.  Where 
the  long  gradual  curve  is  present,  it  shows  a  large 


138  MEMOIR  OF  A.  S.  ROBERTS. 

area  of  inflammation,  but  not  necessarily  a  rapid 
one.  On  the  contrary,  where  only  one  or  two 
vertebrae  are  involved  in  the  carious  process,  the 
deformity  is  sharper  and  well  defined.  In  the 
cervical  and  lumbar  regions  determination  of  the 
amount  of  disease  by  the  appearance  of  the  deform- 
ity is  entirely  unreliable,  the  deformity  in  these 
situations,  owing  to  the  anatomical  position  and 
construction  of  the  vertebrae,  rarely  attaining  the 
proportions  found  especially  in  the  mid-dorsal  spine. 
By  some  authors  it  is  held  that  the  shape  of  the 
curvature  establishes  the  suppurative  or  non-sup- 
purative  character  of  the  lesion.  Thus,  it  has  been 
maintained  that  caries  sicca  frequently  involves  a 
number  of  the  vertebrae  primarily,  the  resulting  pro- 
jection partaking  more  of  the  character  of  a  true 
curvature,  while  but  few  vertebrae  or  only  a  single 
one  are  involved  in  the  acute  suppurative  variety, 
giving  rise  to  the  sharp,  angular  deformity. 

Stage  oe  Abscess.  Among  the  most  common 
of  the  consequences  of  caries  of  the  spine  is  the 
formation  of  abscesses,  which  during  their  formation 
and  course  give  rise  to  important  symptoms.  While 
these,  as  a  rule,  are  more  frequently  met  with  in  the 
later  periods  of  the  disease,  the  patient  is  at  no  time 
exempt  from  them,  and  they  may  occur  at  the  earliest 
time,  even  before  deformity  is  visible.  Again,  some 
cases  run  their  entire  course  without  the  appearance 
of  an  abscess,  while  in  other  cases  abscesses  have 
been  detected,  which  have  disappeared  without 
opening  or  giving  rise  to  any  marked  disturbance. 
These  collections  of  pus,  coming  from  the  carious 


POTT'S  DISEASE.  139 

foci,  follow  the  general  rule  of  the  least  resistance, 
and  in  their  passage  important  parts  and  organs  are 
protected  by  the  fasciae.  It  may  be  stated  that  they 
open  at  some  distance  from  the  point  of  origin  and 
according  to  the  site  of  the  lesion.  The  most  com- 
mon situation  for  the  formation  of  these  abscesses 
may  be  broadly  stated  to  be  found  in  connection 
with  caries  of  the  dorso-lumbar  region.  The  dorsal 
abscesses  find  their  way  beneath  the  ligamentum 
arcuatum  into  the  sheath  of  the  psoas  muscle,  and 
are  guided  by  the  attachment  of  the  sheath  of  this 
muscle  under  Poupart's  ligament  and  into  Scarpa's 
triangle,  where  they  most  commonly  open  and  dis- 
charge their  contents.  Caries  of  the  lower  lumbar 
spine  gives  rise  to  the  so-called  lumbar  or  gluteal 
abscess.  This  has  its  normal  outlet  through  the 
great  sacro-sciatic  notch,  and  most  often  points  at 
the  lower  border  of  the  gluteus  maximus.  Some- 
times these  lumbar  abscesses  appear  posteriorly, 
having  perforated  the  quadriceps  lumborum,  and 
make  their  appearance  at  or  about  the  seat  of  the 
disease.  In  caries  of  the  upper  or  cervico-dorsal 
vertebras  abscesses  pass  in  front  of  or  behind  the 
sterno-mastoid,  or  into  the  posterior  wall  of  the 
pharynx,  where  they  are  known  as  retro-pharyngeal 
abscesses.  Again,  they  may  be  found  in  the  thorax, 
forming  a  mediastinal  abscess,  and  discharge  into 
the  trachea,  bronchi,  or  oesophagus,  or  at  some 
external  point. 

While  we  have,  for  the  convenience  of  the  reader, 
given  the  usual  course  pursued  by  these  spinal 
abscesses,  it  is  not  to  be  understood  that  they  all 


140  MEMOIR  OF  A.  S.  ROBERTS. 

follow  these  methodical  directions.  Indeed,  their 
course  is  subject  to  the  greatest  vagaries.  Thus, 
we  have  records  of  cases  where  the  abscesses  opened 
at  various  abnormal  positions — in  the  mouth,  lungs, 
bronchi,  stomach,  intestines,  bladder,  and  rectum, 
or  in  external  parts  remote  from  the  site  of  forma- 
tion. A  remarkable  circumstance  in  connection 
with  the  course  of  abscesses  connected  with  spinal 
caries  is  the  very  rare  occurrence  of  a  fatal  termina- 
tion directly  traceable  to  them.  We  have,  however, 
already  spoken  of  the  protection  afforded  to  impor- 
tant adjacent  parts  and  organs  by  the  fascia?  along 
which  the  abscess  passes. 

As  a  rule,  not  much  disturbance  of  a  general 
nature  is  experienced  during  the  development  and 
course  of  an  abscess.  The  patient  may  have  an 
exacerbation  of  evening  temperature,  with  slight 
chilliness  and  perspiration.  Pain  is  slightly  in- 
creased, the  latter  ceasing,  however,  as  the  pus 
reaches  an  external  situation,  or  where  inflammation 
does  not  occur  in  the  sac  itself.  The  abscess  may, 
however,  occasion  much  local  disturbance,  according 
to  its  location  and  size.  In  retro-pharyngeal  abscess 
dysphagia  and  suffocative  attacks  may  be  experi- 
enced, and  when  it  opens  into  the  bronchi  there  is 
an  expectoration  of  pus,  attended  by  extreme  dysp- 
noea and  collapse.  All  the  reported  cases  of  rupture 
into  the  peritoneum  and  large  bloodvessels  have 
terminated  fatally.  Abscesses  may  remain  station- 
ary for  a  long  time,  and,  especially  in  children,  give 
rise  to  very  little  disturbance  of  function  or  of  the 
general  health.     Occasionally  they  are,  under  care- 


POTT'S  DISEASE.  141 

ful  mechanical  treatment,  absorbed ;  but,  as  a  rule, 
they  steadily  increase  in  size  and  finally  rupture. 

Stage  of  Paraplegia.  It  so  often  happens  in 
disease  of  the  lower  cervical  and  upper  dorsal  region 
that  we  meet  with  paraplegia  of  the  lower  extremi- 
ties that,  while  it  cannot  perhaps  be  considered  as 
strictly  a  distinct  stage  of  Pott's  disease,  it  is  still 
of  sufficient  importance  to  demand  separate  descrip- 
tion. This  paraplegia,  which  generally  involves 
only  the  motor  functions  of  the  cord,  has  been 
usually  believed  to  be  the  result  of  a  compression- 
myelitis,  and,  while  pathologically  partaking  rather 
of  the  characteristics  of  a  pachymeningitis  or  men- 
ingo-myelitis,  gives  rise  to  such  symptoms  as  would 
ordinarily  result  from  a  myelitis  due  to  pressure, 
either  from  inflammatory  products  or  abscess.  Its 
onset  is  marked  by  a  gradual  diminution  in  the 
strength  of  the  parts  affected,  until  eventually  there 
is  complete  loss  of  power,  but  usually  little  disturb- 
ance of  sensation.  All  the  reflexes  are  increased, 
as  indeed  they  are  very  early,  and  at  times  it  is 
possible  to  prognosticate  the  approach  of  the  para- 
plegic condition  by  this  exaggeration  of  the  patellar 
tendon  and  other  reflexes.  Muscles  which  are  the 
seat  of  paraplegia  become  rigid  and  tense,  and  at 
times  marked  clonus  is  easily  produced,  while  at  a 
later  period,  where  the  paraplegia  has  existed  for  a 
long  time,  permanent  contracture  may  result.  The 
paraplegia  of  Pott's  disease  is  a  bilateral  affection, 
and,  as  before  stated,  usually  involves  the  lower 
extremities.  In  rare  cases  of  dorsal  caries,  more 
frequently  of  upper  cervical,  the  upper  extremities 


142  MEMOIR  OF  A.  S.  ROBERTS. 

may  be  involved.  The  functions  of  the  rectum  and 
bladder  are  rarely  disturbed,  and  there  is  little  inter- 
ference with  the  general  nutrition  of  the  patient, 
atrophy  taking  place  only  in  the  paraplegic  parts. 
Indeed,  it  not  infrequently  happens  that  many  of 
these  patients  gain  flesh,  probably  from  their  forced 
confinement  in  one  position.  Recovery  is  often 
spontaneous,  and  seems  to  be  the  natural  tendency 
of  this  form  of  paraplegia.  Recurring  attacks  are 
not  of  unusual  frequency,  a  case  having  been  under 
my  personal  observation  where  two  attacks  took 
place  with  recovery,  and  other  writers  report  similar 
results.  Cases  have  also  been  reported  where  re- 
covery took  place  with  marked  sensory  disturbance, 
as  in  a  case  under  the  author's  care,  where  both 
sensation  and  motion  were  lost.  As  a  rule,  the 
involvement  of  the  sensory  function  would  render 
the  prognosis  less  favorable  than  where  there  was 
simple  motor  paraplegia, 

DIAGNOSIS. 

It  may  be  stated  as  a  general  axiom  that  diag- 
nosis is  of  value  proportionately  as  it  enables  us  to 
give  early  and  prompt  treatment  to  the  patient,  and 
in  no  disease  is  this  more  pertinent  than  in  the  one 
under  consideration.  ISTo  difficulty  in  diagnosis  is 
experienced  where,  as  is,  unfortunately,  too  often 
the  case,  patients  present  a  kyphosis  and  abscess 
well  marked,  or  a  paraplegia  in  full  progress.  Here, 
however,  the  opportunity  for  relief,  certainly  so  far 
as  deformity  is  concerned,  is  reduced  to  the  mini- 
mum.    Where  we  are  brought  into  contact  with  a 


POTT'S  DISEASE.  143 

case  in  which  we  do  not  find  this  tell-tale  deformity 
or  other  marked  symptoms — in  other  words,  an 
incipient  case — the  question  of  diagnosis  becomes  a 
more  difficult  one,  and  will  necessitate  a  most  care- 
ful inquiry  into  the  symptoms,  both  subjective  and 
objective,  before  we  are  enabled  to  arrive  at  a  proper 
conclusion. 

Examination  of  a  patient  presenting  with  symp- 
toms which  would  indicate  the  existence  of  spinal 
caries  should  be  conducted  in  the  following  manner: 
A  history  should  be  taken,  according  to  a  uniform 
plan,  and  with  especial  reference  to  certain  points. 
The  general  condition,  hereditary  tendencies  to  dis- 
eases, apparent  cause,  and  mode  of  invasion  should 
first  occupy  our  attention.  Secondly,  the  subjec- 
tive symptoms — pain,  etc. — should  be  considered. 
Thirdly,  the  attitude  and  aspect  will  often  give 
valuable  held  in  diagnosis. 

Most  important  is  the  physical  examination  of 
the  patient,  and  this  should  be  conducted  as  follows  : 
The  patient,  after  being  stripped,  is  placed  in  a  good 
light,  and  the  surgeon,  standing  at  his  back,  observes 
any  inequalities  of  the  spinous  processes,  or  any 
deviation  from  the  normal  contour  of  the  spinal 
column.  In  this  way  any  marked  irregularity  will 
be  at  once  manifest.  Spinal  flexibility  should  next 
receive  attention.  In  order  to  have  a  correct  per- 
ception of  the  spinal  rigidity  due  to  reflex  muscular 
spasm,  it  is  necessary  that  a  knowledge  of  the 
normal  mobility  of  the  spine  should  be  obtained, 
and  this  is  tested  best  by  the  "  Adams  method," 
as  follows :  The  patient,  standing  erect,  with  arms 


144  MEMOIR  OF  A.  S.  ROBERTS. 

at  the  side,  should  be  directed  to  touch  the  toes 
with  the  points  of  the  fingers,  the  head  being  thrown 
forward  on  the  chest.  If  the  spine  be  normal,  no 
difficulty  will  be  experienced  in  performing  this 
simple  manoeuvre  ;  should  there  be  any  rigidity,  the 
movement  will  be  checked  at  a  certain  point.  The 
same  test  practically  may  be  applied  to  young  chil- 
dren unable  to  stand,  by  placing  them  prone  on  a 
hard  couch,  the  surgeon  grasping  the  heels  and  ele- 
vating the  whole  lower  segment  of  the  body.  If 
the  spine  be  normal,  it  will  be  surprising,  to  those 
who  have  never  used  this  test,  to  see  what  an 
amount  of  mobility  can  be  obtained  in  this  manner. 
As  the  thighs  ascend,  the  spine  bends,  in  some  cases 
enough  to  allow  the  heels  to  approach  the  occiput. 
This  motion  would  be  checked  at  some  point  of  the 
normal  arc  were  disease  present,  and  the  spine  as- 
sume such  rigidity  that  the  back  would  rise  as  a 
whole.  Lateral  mobility,  which  in  the  normal  spine 
is  considerable  in  extent,  and  of  great  value  in  diag- 
nosis, is  affected  in  a  similar  manner  by  the  presence 
of  disease.  Taken  as  a  ivJiole,  spinal  rigidity  is  the 
most  constant  and  valuable  symptom  we  jwssess  for 
diagnosis,  and,  in  conjunction  with  pain  and  attitude, 
often  enables  us  to  diagnosticate  serious  spinal  caries 
long  before  the  appearance  of  deformity. 

With  these  few  preliminary  remarks,  we  will 
proceed  to  the  study  of  regional  diagnosis  in  Pott's 
disease. 

Cervical  Caries.  The  different  regions  of 
the  spine  affected  with  caries  are  characterized  by 
widely-differing    symptoms,   depending    upon   the 


POTT'S  DISEASE. 


145 


mobility,  nervous  supply,  and  construction  of  the 
vertebras  forming  the  different  segments.  In  the 
cervical  region  we  most  often  have  disease  at  the 
third,  fourth,  and  fifth  vertebrae,  and  the  muscular 


Fig.  34. 


m 

Cervical  caries. 


expression  of  disease  at  this  point  is  quite  charac 
teristic.      The  patients  hold  the  head  rigidly  in  a 
position  either  of  flexion  or  extension,  greater  or 


10 


146  MEMOIR  OF  A.  S.  ROBERTS. 

less  according  to  the  amount  of  the  disease.  (Fig. 
34.)  On  attempting  to  move  the  head,  the  surgeon 
is  resisted  by  marked  reflex  spasm  in  the  direction 
either  of  flexion  or  extension,  yet  mobility  in  rota- 
tion will  be  found  free.  Herein  lies  a  valuable 
diagnostic  point  in  differentiating  disease  of  the 
lower  cervical  from  disease  of  the  two  upper  cervical 
vertebrae,  as  rotation  is  in  the  latter  markedly  and 
invariably  resisted.  Pain  is  referred  to  the  parts 
immediately  below  the  diseased  area.  Pains  radiat- 
ing down  the  arms  and  in  some  cases  to  the  sides 
of  the  neck,  and  even  to  the  superior  parts  of  the 
thorax,  are  most  often  complained  of,  the  pains  fol- 
lowing the  general  rule  and  finding  their  expression 
at  the  periphery  of  the  nerves.  Jars  and  concus- 
sions are  badly  borne,  and  we  are  often  enabled  to 
observe  a  marked  broadening  of  the  neck.  In  the 
attempt  to  hold  the  head  in  such  a  position  that 
concussion  from  jar  is  least  liable  to  be  felt,  the 
spinal  column  below  the  point  of  disease  assumes  a 
compensatory  curve,  giving  a  hollow  appearance  to 
the  dorsal  part  between  the  shoulders,  with  a  pro- 
jection in  the  lumbar  region. 

In  cervical  disease  it  is  sometimes  possible  to  feel 
the  thickened  vertebra3  through  the  mouth,  especially 
where  the  caries  has  advanced  sufficiently  to  occa- 
sion some  breaking  down  of  the  bodies  and  bulging 
forward  of  the  post-pharyngeal  wall,  or,  again, 
where  an  abscess  points  in  this  region.  Paraplegia 
may  be  associated  with  disease  of  this  part. 

Less  frequently  than  disease  of  the  third,  fourth, 
and  fifth,  we  meet  with  disease  of  the  first  and  second 


POTT'S  DISEASE.  147 

cervical  vertebrae,  or  atlo-axoid  disease.  Here  rigid- 
ity is  quite  expressive,  and  of  itself  furnishes  a 
diagnosis.  In  disease  between  the  atlas  and  axis 
all  rotary  movements  are  checked,  and,  while  it  is 
very  rare  that  we  have  uncomplicated  disease  of 
these  two  vertebrae,  a  sufficient  number  of  cases 
occur  to  make  this  limitation  of  motion  strongly 
characteristic.  It  is  in  this  region,  although  not 
exclusively,  that  we  meet  with  the  torticollis  de- 
pendent on  spinal  caries,  and  this  is  sometimes 
difficult  to  distinguish  from  wry-neck  due  to  causes 
independent  of  bone  disease,  but  is  always  a  valua- 
ble aid  to  diagnosis.  The  characteristic  of  this 
symptomatic  torticollis  is  that  in  spinal  caries  the 
head  is  rotated  toward  the  contracted  muscles, 
whereas  in  the  idiopathic  form  of  wry-neck  torsion 
takes  place  away  from  it.  Again,  there  is  a  spas- 
modic feeling  imparted  to  the  muscles  on  movement, 
and  the  posterior  group  are  more  commonly  involved 
than  the  sterno-mastoid  in  the  contraction  due  to 
reflex  spasm.  Ether  abolishes  the  contraction  com- 
pletely. With  atlo-axoid  disease  pain  is  found 
early  in  the  upper  part  of  the  neck  and  in  the  occip- 
ital region,  or,  again,  is  complained  of  in  the  ears, 
the  sides  of  the  neck,  or  the  upper  part  of  the  chest, 
and  is  neuralgic  in  character.  This  pain  is  increased 
by  pressure  on  the  head  or  by  any  movements  affect- 
ing the  upper  part  of  the  spinal  column.  Hilton 
speaks  of  pain  in  atlo-axoid  disease  as  being  always 
unilateral,  and  seems  to  think  that  this  indicates  the 
side  of  the  vertebrae  affected.  Swelling  and  broad- 
ening of  the  neck  also  occur ;  marked  protrusion  of 


148  MEMOIR  OF  A.  S.  ROBERTS. 

the  pharyngeal  wall  can  sometimes  be  felt  with  the 
finger  in  the  mouth,  the  patient  being  subject  to 
attacks  of  dysphagia.  Deformity  appears  at  a 
variable  period,  the  patient  having  adopted  a  pecu- 
liar attitude.  The  head  may  be  flexed  or  extended 
markedly,  with  rotation,  but  usually  it  is  projected 
forward,  and  supported  in  every  possible  position 
by  the  patient,  recumbency  being  the  favorite  pos- 
ture. It  has  been  supposed  that  deformity  in  this 
region  depends  upon  a  forward  luxation  of  the  atlas 
upon  the  vertebras  beneath,  and  the  spinous  process 
of  the  axis  can  often  be  felt  or  seen. 

Abscesses  are  common  in  this  region,  and  present 
frequently  as  "  post-pharyngeal "  collections  of  pus, 
giving  rise  to  serious  symptoms,  which  have  re- 
ceived detailed  description  in  works  on  surgery. 
Abscesses  may  appear  also  at  the  sides  of  the  neck 
posteriorly,  and  follow  the  course  of  other  deep- 
seated  cervical  abscesses.  Nerve  symptoms  are 
very  often  associated  with  atlo-axoid  disease,  vary- 
ing greatly  in  extent,  from  paralysis  of  one  arm  to 
a  more  general  paralysis  of  the  parts  below  the 
neck.  This  is  usually  of  the  motor  type,  but  at 
times  anaesthesia  is  noticed  with  loss  of  vesical  and 
rectal  control.  Cerebral  symptoms  meningeal  in 
character  often  occur,  or  sudden  death  may  take 
place  from  crushing  of  the  spinal  cord. 

Differential  Diagnosis  (Cervical  Region). 
We  have  already  spoken  of  torticollis  as  being  at 
limes  a  symptom  of  caries  of  the  cervical  region 
easily  mistaken  for  idiopathic  wry-neck,  and  have 
given  a  rule  for  its  differentiation.     Among  other 


POTT'S  DISEA SE.  149 

diseases  liable  to  be  mistaken  for  this  serious  malady 
are  lateral  curvature  involving  the  upper  part  of  the 
spine,  muscular  rheumatism,  simple  abscess,  aden- 
itis, acute  traumatic  lesions,  and  hysterical  simula- 
tion of  Pott's  disease.  Lateral  curvature  is  rare  in 
this  region,  and  is  usually  accompanied  by  rotation 
and  marked  by  absence  of  pain  and  reflex  spasm. 
It  should  be  borne  in  mind,  however,  that  a  lateral 
deviation  of  the  spine  may  take  place  early  in  Pott's 
disease,  and  in  any  region,  but  this  disappears,  as  a 
rule,  rapidly  with  the  advent  of  bony  deformity  and 
other  pronounced  symptoms,  and  is  entirely  modi- 
fied by  treatment.  Muscular  rheumatism  is  marked 
by  tenderness  of  the  muscles  themselves  and  by  the 
entire  absence  of  bone  deformity,  and  is  more  apt 
to  take  place  at  a  later  period  of  life.  The  move- 
ments of  the  neck,  while  stiff  and  painful,  give  no 
characteristic  spastic  sensation,  and  the  transitory 
and  shifting  character  of  the  affection  should  leave 
no  doubt  as  to  its  nature.  Simple  abscesses  are 
usually  acute  in  character,  attended  by  high  tem- 
perature, and  their  history  and  superficial  character 
leave  little  room  for  doubt.  Acute  traumatic  lesions 
— dislocation  and  fracture — are  diagnosticated  by 
the  history,  the  sudden  deformity,  and  the  usual 
signs  of  such  injuries  as  met  with  in  other  parts  of 
the  body. 

Hysterical  simulation  is  at  times  exceedingly 
difficult  to  diagnosticate  from  true  spondylitis,  and 
may  be  encountered  in  all  parts  of  the  spinal 
column.  In  the  simulated  condition  pain  is  the 
most  prominent  symptom,  and  is  always  complained 


150  MEMOIR  OF  A.  S.  ROBERTS. 

of  at  the  supposed  seat  of  the  disease,  differing 
from  that  of  true  caries,  which  is  generally  reflected 
to  the  anterior  part  of  the  body.  It  has  all  the 
characteristics  of  an  intense  hyperesthesia,  and 
light  pressure  apparently  gives  rise  to  great  suffer- 
ing, such  as  is  found  in  the  so-called  "  spinal  irrita- 
tion." When  attention  is  diverted,  the  pain  on 
pressure  either  disappears  or  a  new  locality  is  com- 
plained of.  There  is  no  reflex  spasm,  voluntary 
efforts  being  made  to  keep  the  spine  quiet,  and  per- 
sistent gentle  f&rce  usually  overcomes  the  resistance 
to  motion.  Care  must  be  taken  in  estimating  the 
amount  of  motion  present,  our  diagnosis  depending 
largely  on  the  muscular  expression  accompanying 
the  disease.  Whatever  bulging  of  the  vertebrae 
occurs  is  immediately  reduced  by  placing  the  pa- 
tient in  the  prone  position.  Paralysis  of  hysterical 
origin  is  very  common,  and  at  times  is  difficult  to 
distinguish  from  the  paraplegia  of  Pott's  disease. 
It  is,  as  a  rule,  sudden,  differing  from  the  gradual 
loss  of  power  found  in  the  course  of  spondylitis,  is 
more  often  unilateral  or  confined  to  one  extremity, 
and  frequently  disappears  as  suddenly  as  it  came. 

Dorsal  Caries.  The  attitude  of  a  patient  suf- 
fering with  caries  of  the  upper  dorsal  region  suggests 
the  attempt  of  one  endeavoring  to  balance  the  head 
on  the  shoulders.  (Fig.  35.)  The  chin  is  elevated, 
the  spinal  column  below  the  seat  of  disease  is 
straightened,  and  at  times  curved  forward  and  held 
rigidly,  and  the  gait  and  carriage  of  the  patient  are 
those  of  extreme  apprehension.  When  the  bony 
deformity  is  large,  the  head  sinks  between  the  ele- 


POTT'S  DISEASE. 


151 


vated  shoulders,  giving  a  characteristic  "  turtle- 
head  "  appearance.  Pain  in  disease  of  this  region 
is  referred  to  the  chest  and  sides,  and  often  there  is 
disturbance  of  the  respiratory  function,  as  mani- 
fested by  a  peculiar  "  grunting,"  at  times  accom- 


Fig.  35. 


Dorsal  caries. 

panied  by  cough,  dyspnoea,  and  partial  cyanosis. 
Interference  of  motion  at  this  portion  is  detected 
with  some  difficulty,  owing  to  the  fact  that  nor- 
mally here  is  the  most  rigid  and  unyielding  portion 
of  the  spinal  column.    This,  however,  is  sufficiently 


152  MEMOIR  OF  A.  S.  ROBERTS. 

well  marked  and  appreciated,  especially  when  the 
other  symptoms  present  are  taken  into  considera- 
tion. Paraplegia  is  most  often  found  in  connection 
with  disease  of  the  upper  dorsal  spine,  and  affects 
chiefly  the  lower  extremities.  Reference  to  this  has 
already  been  made  under  the  head  of  Symptom- 
atology. 

Mid-dorsal  disease  gives  rise  to  the  typical  "hunch- 
back," the  most  persistent  deformity  taking  place  in 
this  region.  The  progressive  character  of  the  lesion 
is  due  to  several  reasons.  It  is  in  this  locality, 
especially  the  superior  dorsal,  that  we  contend  with 
the  constant  traumatism  of  respiration,  and,  having 
a  fixed  projection  in  the  middle  of  a  flexible  column, 
the  application  of  proper  supports  becomes  a  matter 
of  great  difficulty.  The  attitude  assumed  by  patients 
with  disease  in  this  region  is  an  exaggeration  of  the 
one  described  under  disease  of  the  upper  dorsal 
spine.  A  marked  rigidity  in  stooping  or  lifting 
articles  from  the  floor  is  noticed.  The  patient  in 
performing  these  movements  lowers  the  body  as  a 
whole,  bending  his  knees  and  hips,  and  gradually 
approaches  the  article  he  wishes  to  raise,  resuming 
the  upright  position  with  infinite  care,  never  allow- 
ing the  spine  to  bend.  Pain  is  marked,  especially 
on  motion,  and  is  referred  most  frequently  to  the 
lower  part  of  the  thorax  and  stomach,  giving  the 
"  initial  gastralgia  "  so  often  complained  of,  and  at 
times  coming  on  very  early  in  the  course  of  the 
disease,  antedating  even  the  appearance  of  the 
deformity.  It  is  of  great  importance  to  realize 
distinctly  the  connection  of  this   pain  with  spinal 


POTT'S  DISEASE.  153 

caries,  as  many  children  are  treated  during  long 
periods  for  many  different  diseases — indigestion, 
worms,  and  other  disorders  of  the  digestive  tract 
being  not  infrequently  assumed  as  the  cause  of  the 
pain.  The  pain  is  frequently  accompanied  by  the 
so-called  "  osteitic  cry,"  and  occurs  most  often  at 
night,  this  cry  being  in  character  very  much  like 
that  of  acute  hydrocephalus,  and  found  in  connec- 
tion with  disease  of  the  bone  in  any  part  of  the 
spine  or  of  the  articulations. 

Disease  of  the  lower  dorsal  spine  is  so  intimately 
associated  with  lumbar  caries  that  it  will  be  best 
considered  in  the  description  of  that  region. 

Differential  Diagnosis  (Dorsal  Region). 
Before  the  appearance  of  deformity  causing  abnor- 
mal curves  to  appear  in  the  spine,  aneurism  of  the 
thoracic  and  abdominal  aorta,  eroding  the  vetebral 
bodies,  as  evinced  in  two  autopsies  the  author  had 
opportunities  of  making,  may  give  rise  to  symptoms 
similar  to  those  of  spinal  caries.  Diagnosis  by 
auscultation  and  the  presence  of  other  symptoms 
usually  establish  the  nature  of  this  lesion  before 
the  spine  is  much  affected,  and  the  extensive  curve 
and  localized  pain  are  sufficient  to  demonstrate  the 
existence  of  aneurism. 

Malignant  growths,  cancer,  etc.,  are  rarely  seen 
in  children. 

Chronic  pleurisy,  with  effusion  or  empyema,  and 
other  inflammatory  lung  troubles,  would  be  excluded 
by  physical  signs. 

Rhachitic  curves  are  very  common  in  the  dorsal 
region  (Fig.  36),  but  are  marked  by  their  gradual 


154 


MEMOIR  OF  A.  S.  ROBERTS. 


character  and  extent,  and  are  attended  by  the  char- 
acteristic large  head,  flattened  epiphyses,  general 
tenderness,  and  inability  to  walk.  Motion  is  rarely 
limited,  the  curvature  mostly  disappearing  in  the 


Fig.  36. 


Functional  spinal  debility  simulating  caries. 


prone  position.  Pain,  when  present,  is  local  in 
character,  and  the  general  listless  appearance  of  the 
patient  serves  to  explain  the  functional  curve. 

Disease  of  the  Lumbar  Region.  Disease  of 
the  lower  segment  of  the  vertebral  column,  which 
will  here  include  the  lower  dorsal  and  lumbar  ver- 
tebrae, presents  some  especially  important  features 
from  the  stand-point  of  diagnosis.     It  is  here  that 


POTTS  DISEASE. 


155 


we  have  to  deal  with  a  portion  of  the  spine  largely 
controlled  by  the  psoas  muscles,  and  the  reflex  limi- 
tation of  motion  at  this  point  gives  us  most  valua- 
ble indications  concerning  not  only  the  condition  of 
the  vertebrae,  but  also  the  presence  and  progress  of 

Fig.  37. 


Lumbar  caries. 


abscess,  which  is  more  often  encountered  here  than 
in  disease  of  any  other  part  of  the  spine.  Here, 
again,  a  special  attitude  is  assumed  by  the  patient, 
in  most  cases  consisting  of  a  "  lordosis,"  or  an  ante- 
rior curvature  of  the  spine.     This  is  nature's  mode 


156  MEMOIR  OF  A.  S.  ROBERTS. 

of  protecting  the  diseased  parts,  there  being  a  con- 
servative attempt  made  to  throw  the  weight  of  the 
body  from  the  diseased  vertebral  bodies  on  to  the 
articulating  facets.  The  reflex  muscular  spasm  is 
best  appreciated  here  by  placing  the  patient  in  the 
prone  position  and  making  the  movement  already 
described  in  the  general  remarks  on  diagnosis.  (See 
Fig.  37.)  As  stated,  the  condition  of  the  psoas 
muscle  furnishes  us  with  excellent  indications  as  to 
the  presence  or  absence  of  abscess  in  its  sheath. 
If,  the  patient  being  prone,  the  surgeon  makes 
pressure  on  the  pelvis  with  one  hand,  holding  it 
firmly  in  one  position,  and,  grasping  the  thigh  with 
the  other  hand,  the  knee  having  previously  been 
flexed,  attempts  to  extend  the  thigh  on  the  pelvis, 
should  contraction  of  the  psoas  exist  he  will  be  met 
by  a  decided  limitation  in  the  extension  of  the  thigh. 
The  application  of  this  test,  one  of  the  utmost  im- 
portance, is  easily  learned,  and,  in  conjunction  with 
palpation  of  the  pelvic  fossae  and  with  the  general 
symptoms  of  pain,  temperature,  etc.,  will  usually 
show  the  presence  or  absence  of  an  abscess.  This 
limited  extension  is  generally  found  unilaterally,  but 
may  be  bilateral,  and  on  the  emergence  of  the 
abscess  from  the  pelvic  cavity  usually  disappears. 
Pain  from  caries  of  the  dorso-lumbar  spine  is  re- 
ferred to  the  hypogastric  region  and  the  lower 
extremities. 

Paraplegia  with  this  form  of  spondylitis  is  among 
the  rarest  of  complications,  for  well-known  anatom- 
ical reasons.  Deformity,  as  in  the  cervical  region, 
rarely  reaches  the  degree    met  with    in    the   mid- 


POTT'S  DISEASE.  157 

dorsal  spine,  and  in  many  cases  where  the  disease 
is  confined  exclusively  to  the  lumbar  vertebrae  little 
or  no  deformity  is  noticeable. 

Differential  Diagnosis  (Lumbar  Region). 
Many  diseases  may  occur  at  or  about  this  part  of 
the  vertebral  column  with  spinal  caries,  and  the 
knowledge  and  experience  of  the  surgeon  will  often 
be  severely  tested  in  differentiating  between  them. 
Disease  of  the  last  lumbar  vertebra  is  often  mis- 
taken for  hip-joint  disease,  the  converse  being  also 
true. 

Sacro-iliac  disease,  perityphlitis  and  nephritis, 
sciatica,  lumbago,  and  other  diseases  may  also 
obscure  the  diagnosis ;  but  space  forbids  a  detailed 
account  of  the  symptoms  and  methods  used  for 
differential  diagnosis,  the  reader  being  referred  to 
the  articles  on  these  subjects  in  other  portions  of 
this  work. 

GENERAL    PROGNOSIS. 

In  general  terms  it  may  be  stated  that  the  prog- 
nosis of  Pott's  disease  depends  largely  on  that 
portion  of  the  spinal  column  affected  by  the  caries. 
Thus,  the  best  results  of  treatment  are  usually 
obtained  in  the  cervical  and  lumbar  regions,  at  times 
lasting  many  years,  although  so-called  acute  cases 
have  been  reported.  Much  of  the  success  achieved 
in  later  times  in  the  treatment  of  spondylitis  may 
be  ascribed  to  a  more  correct  interpretation  of  the 
symptoms,  to  a  better  knowledge  of  the  etiology 
and  of  the  mechanics  of  the  parts,  and,  above  all 
to  a  better  adaptation  of  the  various  supports  used 


158  MEMOIR  OF  A.  S.  ROBERTS. 

in  the  treatment  of  the  diseased  areas.  Prognosis 
will  always  be  affected  by  the  amount  of  personal 
attention  given  by  the  surgeon,  by  the  home  care 
of  the  patient,  and  by  the  detail  with  which  the 
mechanical  treatment  is  carried  out.  During  the 
progress  of  a  case  the  symptoms  may  be  held  in 
abeyance  for  a  long  time,  and  the  inexperienced 
surgeon,  judging  from  the  cessation  of  pain,  the 
apparent  arrest  of  deformity,  and  the  non-appearance 
of  abscess,  may  remove  the  apparatus,  thinking  his 
patient  cured.  Very  soon,  however,  he  is  unde- 
ceived ;  the  symptoms  become  more  acute  in  char- 
acter and  assume  an  alarming  aspect,  the  patient 
having  one  of  the  exacerbations  known  to  every  one 
familiar  with  these  cases.  The  earlier  the  diagnosis 
is  made  and  the  child  placed  under  mechanical  treat- 
ment and  good  hygienic  conditions,  the  better  the 
prognosis.  Notwithstanding  the  fact  that  the 
strumous  or  tubercular  diathesis  usually  underlies 
the  lesion,  many  patients  recover,  with  more  or  less 
deformity,  and  sometimes  live  to  advanced  age. 
The  deformity  when  once  present  rarely  disappears, 
although  it  may  be  diminished  at  times  by  treatment. 
Abscess  was  formerly  regarded  as  a  symptom  of 
the  utmost  gravity  as  affecting  prognosis,  but  many 
patients  recover,  with  strong,  though  sharply-de- 
formed backs,  who  have  had  one  or  more  abscesses. 
Ii  is  an  undoubted  fact  that  many  abscesses  form 
and  entirely  disappear,  protective  treatment  modify- 
ing their  course  to  a  very  large  extent.  Abscesses 
which  suppurate  and  discharge  by  fistulous  openings 
for  a  long  time  are  necessarily  of  grave  import  in 


POTTS  DISEASE.  159 

making  a  prognosis,  owing  to  the  ultimate  involve- 
ment of  internal  organs,  amyloid  degenerations 
oftentimes  causing  death  from  kidney  and  liver 
complications. 

Paraplegia,  while  a  distressing  complication  and 
alarming  alike  to  the  parents  and  the  attendants,  is, 
as  a  rule,  recovered  from,  often  spontaneously, 
although  usually  it  lasts  for  a  long  time.  An 
exception  to  this  is  found  in  the  paralysis  attending 
upper  cervical  disease,  where  sudden  death  may 
take  place  from  crushing  of  the  cord  or  involvement 
of  the  respiratory  centre,  or,  again,  where  motion 
and  sensation  are  both  involved,  incurable  paralysis 
often  remains.  We  have  discussed  this  complica- 
tion at  some  length  in  a  former  section. 

Death  often  occurs  from  rupture  of  an  abscess 
internally,  from  intercurrent  inflammations,  such  as 
pneumonia  and  tubercular  meningitis,  or  from  ex- 
haustion following  long-continued  discharges.  The 
acute  exanthemata  have  a  deleterious  effect  on  the 
progress  of  caries,  and  pertussis  is  a  particularly 
dangerous  complication,  especially  in  disease  of  the 
thoracic  vertebra,  the  affection  of  the  spine  advanc- 
ing rapidly,  the  patient  often  dying  in  a  paroxysm. 
Hemorrhage  from  perforation  of  large  bloodvessels, 
and  suffocation  from  discharge  of  abscesses  into 
the  lungs,  have  also  been  reported  as  complications 
with  a  fatal  termination. 

TREATMENT. 

The  modern  treatment  of  Pott's  disease  has 
attained  a  measure  of  excellence  attested  in  a  hio-h 


160  MEMOIR  OF  A.  S.  ROBERTS. 

degree  by  the  much  less  frequent  sight  of  those 
distressing  deformities  which  were  at  one  time  so 
common.  Much  of  this  is  due  to  the  improved 
means  not  only  of  treatment  but  also  of  early  diag- 
nosis, and  to  American  surgery  is  largely  due  the 
advance  in  this  formerly  much  neglected  branch  of 
medicine.  In  commencing  the  treatment  of  caries 
of  the  spine  a  consideration  of  the  pathological 
state  that  we  have  to  deal  with  is  of  the  utmost 
importance.  It  must  be  remembered  that  there 
exists  in  this  condition  a  retrograde  rather  than  a 
reparative  process,  one  which  in  its  course  is  entirely 
different  from  the  process  that  follows  an  acute 
traumatic  lesion.  Instead  of  its  being  a  question 
of  days  or  weeks,  months  and  sometimes  even  years 
are  necessary  to  effect  a  cure. 

There  being  this  long-continued  drain  on  the 
S3^stem,  it  is  obvious  that  the  care  of  the  general 
health  should  receive  as  much  attention  at  our 
hands  as  the  local  condition,  which  in  most  in- 
stances is  but  the  expression  of  a  general  constitu- 
tional state. 

The  principles  of  treatment  to  be  constantly  held 
in  view  should  be  those  which  aim  at  (1)  improve- 
ment of  the  general  health  and  (2)  proper  rest  to 
the  diseased  parts,  which  embraces  the  question  of 
correct  mechanical  support. 

Before  mentioning  those  remedies  which  have 
been  found  of  service  as  general  reconstructive 
agents,  we  would  insist,  in  every  case  where  it  is 
possible,  on  the  importance  of  fresh  air  and  sun- 
light, the  influence  of  which  has  been  recognized 


POTT'S  DISEASE.  161 

and  has  largely  aided  in  bringing  abont  the  good 
results  of  modern  treatment.  We  have  ventured 
to  speak  of  these  agents  before  mentioning  the 
more  generally  used  medicines,  feeling,  as  we  do, 
that  if  restricted  to  a  choice,  we  should  select  these 
hygienic  means  as  against  internal  medication.  All 
such  medicines  as  tend  to  "bone-building"  are  of 
value  in  this  disease,  and  the  selection  of  one — 
whether  it  be  cod-liver  oil,  the  compound  syrup  of 
the  hypophosphites,  phosphorus,  or  any  of  the  tonics, 
mineral  or  vegetable — depends  largely  on  the  con- 
dition of  the  individual  case  and  the  judgment  of 
the  practitioner. 

Under  the  second  division  all  those  means  which 
have  for  their  object  proper  rest  of  the  diseased 
parts,  and  which  include  recumbency  and  splints 
or  braces,  will  be  considered.  The  question  of  rest 
encounters  at  present  no  dissent  except  from  those 
whose  experience  and  clinical  opportunities  hardly 
entitle  them  to  speak  with  authority.  On  the 
mode  of  giving  proper  support  there  is  still  much 
difference  of  opinion. 

The  treatment  by  recumbency  has  had  and  still 
has  its  advocates ;  its  chief  merit  consists  in  the 
fact  that  in  the  recumbent  position,  whether  prone 
or  supine,  there  is  no  superincumbent  weight  press- 
ing upon  the  spine.  Where  other  means  are  not  at 
hand,  it  is  well  that  the  recumbent  posture  should 
be  advised ;  but  the  utter  failure  of  simple  recum- 
bency is  easily  explained  by  the  difficulty  of  keeping 
a  patient  in  bed,  in  one  position,  without  other 
means.     It  is  often  necessary,  even  with  good  me- 

11 


162  MEMOIR  OF  A.  S.  ROBERTS. 

chanical  support,  that  a  patient  should  be  confined 
to  bed,  especially  where  exacerbations  occur  or  a 
paraplegia  is  in  progress.  Thus  recumbency  be- 
comes an  aid  rather  than  a  mode  of  treatment,  and 
in  this  way  has  a  legitimate  place  in  our  therapeu- 
tics of  Pott's  disease.  The  effect  of  recumbency 
on  the  general  health,  especially  in  strumous  cases, 
has  been  variously  estimated.  Many  believe  that, 
by  lessening  the  pain  and  irritation,  the  general 
health  has  improved.  Personally  the  results  ob- 
tained by  us  with  other  means  have  been,  as  a  rule, 
so  favorable  that  we  have  not  had  occasion  to  test 
its  merits  from  this  stand-point. 

Extension  and  suspension  are  modes  of  treatment 
which  have  been  used  for  a  long  time,  and  which 
have  recently  been  brought  into  prominence.  The 
former  has  been  used  with  advantage  in  cervical 
disease,  but  here  again  the  treatment  by  this  method 
necessitates  the  recumbent  posture,  and,  unless 
under  exceptional  circumstances,  we  prefer  the  use 
of  apparatus  which  allows  fresh  air  and  sunlight, 
while  the  patient  receives  proper  support  at  the 
same  time. 

Suspension  as  a  mode  of  treatment  in  caries  of 
the  spine  is  now  generally  used  simply  to  allow  of 
the  application  of  plastic  supports.  As  a  remedial 
agent  it  is  of  no  value  independent  of  support.  The 
idea  formerly  entertained,  that  by  suspension  path- 
ological curves  could  be  obliterated,  no  longer  pre- 
vails, it  having  been  demonstrated  that,  while  the 
physiological  curves  may  be  altered  or  even  obliter- 
ated, the  gibbous  curvedoes  not  change  its  character. 


POTTS  DISEASE.  163 

Suspension  should  always  be  practised  with  the 
greatest  care,  and  always  under  the  direction  and 
in  the  presence  of  the  surgeon  or  an  assistant. 

Mechanical  Treatment.  The  plan  pursued 
in  the  section  on  diagnosis — namely,  the  regional 
one — will  be  continued  in  the  consideration  of  treat- 
ment. ^N"o  attempt  will  be  made  to  consider  the 
numberless  mechanical  devices  used  in  the  treat- 
ment of  Pott's  disease,  only  those  receiving  atten- 
tion which  in  the  hands  of  the  author  have  been 
found  to  be  most  easy  of  adjustment  and  modifica- 
tion, and  which  mechanically  are  capable  of  meeting 
the  indications  in  the  greatest  number  of  cases. 
The  principles  underlying  the  question  of  all  such 
apparatus  as  are  used  in  the  treatment  of  Pott's 
disease  ought  to  be  such  as  will  enable  us  to  secure 
certain  objects.  Chief  among  these  are,  first,  the 
prevention  of  undue  traumatism ;  second,  the  avoid- 
ance, as  far  as  is  practicable,  of  any  movement  of 
the  diseased  parts  ;  and,  last,  the  prevention,  where 
possible,  of  increase  of  pain  and  deformity.  In  the 
present  state  of  our  knowledge,  there  is  no  appa- 
ratus that  will  satisfactorily  accomplish  all  these 
indications,  and  we  have  already  stated  why  this 
lesion  presents  difficulties  in  the  way  of  treatment, 
from  a  pathological  stand-point,  entirely  different 
from  those  which  present  themselves  in  the  treat- 
ment of  an  acute  traumatic  trouble.  Were  the 
anatomical  opportunities  present,  as  they  are  in 
other  articulations,  for  making  proper  traction  on 
the  diseased  parts,  there  could  be  no  doubt  as  to  the 
superiority  of  this  method ;  but  the  application  of 


164  MEMOIR  OF  A.  S.  ROBERTS. 

continuous  traction  to  certain  localities  of  the  spine, 
the  subject  of  carious  inflammation,  and  the  limita- 
tion of  such  traction  force,  are  not,  in  our  opinion, 
possible. 

The  treatment  of  Pott's  disease  by  the  plaster-of- 
Paris  jacket,  as  popularized  by  Prof.  Say  re,  has  of 
late  years  received  so  many  adherents  and  been  so 
universally  accepted  as  an  easy  mode  of  treating 
this  disease  that  a  few  words  concerning  it  and 
similar  plastic  supports  will  not  be  out  of  place. 
It  is  an  undeniable  fact  that  any  apparatus  which 
gives  protection  from  undue  motion  and  traumatism 
to  certain  diseased  areas  will  afford  relief,  and  for 
giving  us  a  ready  means  of  treating  such  localities 
Prof.  Sayre's  method  is  of  the  greatest  value.  This 
is  particularly  true  of  the  dorso-lumbar  region, 
which  is  the  most  easily  controlled  of  any  portion 
of  the  spine. 

There  are,  however,  certain  disadvantages  con- 
nected with  the  use  of  any  plastic  material,  which 
are  of  sufficient  importance  to  receive  attention. 
The  encircling  the  body  in  any  solid  support  pre- 
vents the  surgeon  from  having  the  opportunity  of 
carefully  watching  the  progress  of  the  disease,  and 
of  estimating  the  condition  of  the  skin,  so  that  it 
shall  receive  proper  care.  Ulcerations  or  abscesses 
may  form  without  his  knowledge,  and  no  modifica- 
tion of  the  apparatus  is  possible  without  removal 
and  renewal.  The  improvement  which  ensues  on 
the  application  of  any  apparatus  giving  immobility 
is  such  that  patients,  as  well  as  surgeons,  are  apt 
to  be  deceived  by  the  amelioration  of  the  symptoms. 


POTTS  DISEASE.  165 

and  hence  escape  the  strict  watch  necessary  in  these 
cases.  Thus  the  plastic  envelope  may  be  borne  for 
months,  the  disease  constantly  advancing,  and  the 
patient  returning  only  at  rare  intervals,  owing  to 
the  absence  of  the  acute  manifestations.  Among 
the  poor,  while  it  has  the  advantage  of  cheapness, 
the  lack  of  cleanliness  is  a  drawback  to  the  use  of 
the  plaster,  which  those  in  public  practice  cannot 
have  failed  to  notice.  It  is  obvious,  therefore,  that, 
while  possessing  the  advantages  of  economy,  of 
needing  less  special  experience  than  is  required  for 
the  application  and  modification  of  steel  braces,  and 
of  being  entirely  beyond  the  control  of  the  patient, 
these  are  offset  by  the  disadvantages  already  men- 
tioned. 

It  is  not  an  easy  thing  to  apply  a  proper  jacket, 
and  it  requires  considerable  experience  to  apply  an 
efficient  one,  its  improper  application  being  apt  to 
do  great  harm.  A  brief  description  of  its  mode  of 
application  will  suffice  here ;  for  a  fuller  account  the 
reader  is  referred  to  Dr.  Sayre's  work  on  "  Spinal 
Disease  and  Curvature,"  London,  1877. 

Suspension  is  obtained  by  securing  the  head  in  a 
sling,  which  is  attached  to  a  strong  cord  playing  in 
a  pulley  and  fastened  to  a  staple  driven  into  a  firm 
place  above  the  patient's  head.  The  patient  having 
previously  had  a  tight-fitting,  seamless  undershirt 
applied,  suspension  is  begun.  The  cord  attached 
to  the  pulley  is  so  pulled  that  the  patient's  heels  are 
raised  from  the  floor.  Freshly-prepared  plaster,  of 
the  best  dental  variety,  having  been  rubbed  into 
cross-barred  crinoline  or  other  loose-meshed  cloth, 


1(36 


MEMOIR  OF  A.  S.  ROBERTS. 


and  rolled  into  bandages,  is  then  applied.  These 
bandages  should  before  application  be  placed  in 
water  until  bubbles   cease  to   appear.     The  parts 


I       lor'8   modification  of  Davis's  spinal  assistant.       (From  Transac- 
tion- oi  the  Americas  Orthopedic  Association,  vol.  i.,  1889.) 


POTT'S  DISEASE.  167 

most  liable  to  excoriation  are  carefully  padded,  and 
over  the  abdomen  a  ';  dinner-pad  "  is  applied,  which 
is  afterward  removed,  in  order  to  prevent  too  great 
pressure.  In  females  the  mammae  are  also  padded. 
The  bandages  should  be  put  on  smoothly,  and  as 
high  as  possible,  and  there  should  be  no  inequalities 
or  differences  in  thickness  between  the  front  and 
the  back  portion.  After  the  plaster  has  hardened, 
the  patient  is  placed  on  a  smooth  soft  surface,  and 
all  rough  edges  are  cut  away,  making  the  support 
as  comfortable  as  possible.  Plastic  supports  of  dif- 
ferent materials  may  be  applied  without  suspension. 

Fixative  Apparatus.  Apparatus  of  different 
constructions,  and  representing  many  principles,  are 
in  use ;  but  we  have  personally  had  such  excellent 
results  from  the  anteroposterior  support  as  modi- 
fied by  C.  F.  Taylor,  of  New  York,  that  in  closing 
the  account  of  treatment  we  shall  speak  of  this 
alone.     (Fig.  38.) 

The  antero-posterior  splint  acts  upon  the  prin- 
ciple of  a  lever,  with  its  fulcrum  at  the  point  of 
deformity.  The  apparatus  is  constructed  as  follows : 
Two  uprights  made  of  the  best  annealed  steel,  al- 
lowing of  easy  bending  and  modification  of  shape, 
are  connected  above  by  a  transverse  bar,  giving 
attachment  for  the  shoulder-pieces,  and  below  by 
a  pelvic  band.  (Fig.  39.)  At  the  location  of  de- 
formity, and  where  we  wish  them  to  serve  as  a 
fulcrum,  are  placed  the  pad-plates,  which  extend  for 
some  distance  above  and  below  the  deformity,  and 
should  always  be  sufficiently  long  to  include  the 
entire  area  of  disease.      These  are  pieces  of  steel 


168 


MEMOIR  OF  A.  S.  ROBERTS. 


slightly  wider  than  the  uprights,  and  are  fastened 
to  the  uprights  by  hinges  allowing  of  easy  removal 
and  modification.  In  some  cases  they  may  be 
screwed  to  the  upright  without  hinges.     They  are 


Fig.  39. 


Davis's  spinal  assistant. 


padded  with  various  materials,  ground  cork  being 
the  best.  The  uprights  should  be  so  widely  sepa- 
rated that  the  pressure  of  the  pad-plates  will  come 
on  the  transverse  process,  and  never  on  the  spinous 
ones.  The  uprights  should  extend  high  enough  to 
give  sufficient  leverage,  and  below  to  the  anal  com- 
missure, and  the  pelvic  band  should  be  broad  and 
strong,  extending  from  trochanter  to  trochanter. 
Cross-pieces  for  the  insertion  of  buckles  which  are 
attached  to  the  anterior  support  or  apron  are  placed 
at  points  corresponding  to  the  upper  border  of  the 


POTT'S  DISEASE.  169 

axillae  and  the  lower  angle  of  the  scapulae,  and  are 
attached  to  the  uprights  by  screws.  The  anterior 
part  of  the  support  consists  of  an  apron  made  of 
strong  jean  or  other  similar  material,  and  this  serves 
to  fasten  the  trunk  to  the  apparatus.  It  reaches 
from  the  upper  border  of  the  axillae  in  front  to  a 
point  just  above  the  symphysis  pubis.  Webbing 
straps  are  attached  at  different  points  for  attach- 
ment into  the  buckles  of  the  cross-pieces  and  pelvic 
band,  and  to  the  shoulder-pieces  are  attached  padded 
axillary  straps. 

The  apparatus  is  applied  as  follows  :  The  patient 
is  placed  in  the  recumbent  posture  on  a  hard  even 
couch,  with  the  apron  applied  to  the  anterior  part  of 
the  trunk.  The  brace,  previously  fitted  to  the  con- 
tour of  the  spine,  is  first  secured  by  the  pelvic  band 
and  by  axillary  straps  which  pass  to  the  lower  cross- 
piece.  The  upper  strap  of  the  apron  is  then  attached 
to  the  upper  cross-piece.  These  are  the  important 
and  essential  points  of  attachment,  and  should 
always  be  made  firm.  Supplementary  webbing 
straps  and  buckles  may  be  attached  to  the  apron  to 
give  more  firmness  to  the  support. 

Principles  of  the  Antero-posterior  Support.  The 
antero-posterior  support  acts,  as  has  already  been 
stated,  on  the  principle  of  a  lever  with  a  fulcrum  at 
the  location  of  the  deformity  (Fig.  40)  and  acting 
through  the  transverse  processes.  The  pelvis  is 
another  point  of  pressure,  forming  the  base  of  the 
support,  and  the  resistance  is  furnished  anteriorly 
by  the  superior  thoracic  wall  and  the  traction  of 
the  shoulder  straps  passing  under  the  axillae.     The 


170 


MEMOIR  OF  A.  S.  ROBERTS. 


power  is  maintained  by  the  two  uprights  to  support 
the  spine  in  the  same  position  as  is  gained  by  the 
recumbent  posture. 

Fig.  40. 


Diagram  showing  the  principle  of  Davis's  support. 


There  are  certain  rules  concerning  the  application 
of  the  antero-posterior  brace  which  should  be  care- 
fully followed.  It  should  always  be  put  on  in  the 
recumbent  posture.  The  pressure  should  be  en- 
tirely equable  over  the  transverse  processes,  as 
made  by  the  pad-plates,  and  the  shoulder-pieces 
should  never  press  on  the  shoulders,  it  being  well 
to  leave  a  small  space  between  the  lower  surface  of 
the  shoulder-pieces  and  the  shoulders.  The  axillary 
pads  should  run  in  such  a  direction  that  no  constric- 
tion will  occur  on  the  axillary  vessels  and  nerves. 
The  brace  should  be  worn  day  and  night,  unless 


POTTS  DISEASE.  171 

removed  for  some  special  reason  or  complication, 
and  in  no  case  should  a  patient  with  a  carious  spine 
be  allowed  to  assume  the  upright  position  without 
support.  Bathing  should  be  done  by  sponging  the 
body,  the  patient  being  recumbent. 

For  ease  of  application,  for  convenience  of  modi- 
fication and  inspection,  for  comfort  and  cleanliness 
to  the  wearer,  and  for  maintaining  the  proper  press- 
ure, we  know  of  no  apparatus  which  will  compare 
with  the  antero-posterior  brace.  With  a  little  care 
in  adjusting  the  apparatus,  it  is  within  the  province 
of  every  surgeon  to  secure  with  it  the  most  satis- 
factory results. 

Measurements  for  Ajjparatus.  It  is  important 
that  the  surgeon  should  be  fully  equipped  not  only 
to  measure  for  his  apparatus,  but  also,  when  it  is 
sent  to  him  in  crude  form,  to  be  able  to  fit  it  and 
modify  it,  so  that  nothing  is  left  to  the  instrument- 
maker  but  its  manufacture. 

It  is  measured  for  as  follows :  The  patient  is 
placed  on  a  hard  surface  in  the  prone  position.  A 
strip  of  flexible  lead  or  block-tin,  which  retains  its 
form,  is  laid  over  the  spinous  processes  from  the 
neck  to  the  anal  commissure,  and  all  the  inequalities 
are  carefully  moulded  with  the  lead.  This  is  then 
placed  on  a  stencil-board  or  ordinary  pasteboard, 
and  the  inner  outline  traced  with  great  care.  This 
outline  is  then  cut  out  with  scissors,  and  marks 
places  on  the  pattern  for  the  position  of  the  pad- 
plates,  cross-pieces,  and  shoulder-pieces.  The  pelvic 
measurement  is  taken  from  trochanter  to  trochanter. 
The  pattern   serves   a  double  purpose,   being  the 


172 


MEMOIR  OF  A.  S.  ROBERTS. 


guide  for  the  instrument-maker,  and  also  a  record 
of  the  deformity  at  the  time  of  measurement,  and 
should  be  kept  for  future  observation. 

Treatment  op  Cervical  Caries.  Under  this 
head  will  be  included  the  treatment  of  caries  extend- 
ing to  the  seventh  dorsal  vertebrae,  as  above  this 
point  we  have,  in  order  to  get  efficient  support,  to 

Fig.  41. 


ipM 


Spinal  support,  with  chin-rest,  for  treatment  of  upper  dorsal  and 
cervical  caries. 


extend  the  arm  of  the  lever  superiorly.  This  is 
best  done  by  means  of  Taylor's  chin-piece,  which 
is  secured  to  the  uprights  by  means  of  a  "  keeper 
and  pivot."  (Fig.  41.)  A  modification  of  this  has 
been  devised  by  Dr.  Shaffer,  in  the  form  of  a  ball- 
and-socket  joint  (Fig.  42),  which  allows  of  motion 
in  all  directions,  which  can  be  locked  at  any  point, 


POTT'S  DISEASE. 


173 


and  in  which  the  head  can  be  treated  in  the  position 
of  deformity,  and  so  held  and  modified  from  time  to 
time.  It  is  important  that  the  chin-piece  (Fig.  43) 
surmounting  the  apparatus  should  not  be  too  large, 
and  its  measurement  represents  only  the  occipito- 
mental diameter. 

Fig.  42. 


Ball-and-socket  joint  for  accurate  adaptation  of  chin-rest, 

In  this  region,  it  must  be  remembered,  we  are 
dealing  with  a  rigid  projection  in  the  middle  of  a 
flexible  column.  It  is  thus  not  easy  to  secure  ade- 
quate support,  especially  in  the  upper  dorsal  region, 
and  the  addition  of  the  superior  lever  by  means  of 
the  chin-piece  is  of  great  importance. 

Fig.  43. 


Chin-rest. 


In  the  cervical  region  above  the  second  dorsal 
vertebrae,  treatment,  as  a  rule,  is  attended  by  excel- 


174  MEMOIR  OF  A.  S.  ROBERTS. 

lent  results.  It  is  sometimes  necessary  still  further 
to  supplement  our  chin-piece  by  the  addition  of 
occipital  uprights  (Fig.  41),  which  increase  the  sup- 
port. Traction-force  is  not  attempted  with  the 
chin-piece,  immobility  being  the  object  primarily  in 
view.  In  some  cases  where  the  expense  of  a  steel 
brace  is  of  moment,  disease  in  this  region  may  be 
treated  by  means  of  a  pedestal  of  plaster  encircling 
the  trunk,  into  which  the  chin-piece  with  ball-and- 
socket  pivot  can  be  adjusted.  The  advantages  of 
the  chin-piece  in  the  treatment  of  disease  of  the 
upper  portion  of  the  spine  are  its  lightness,  firm- 
ness, and  inconspicuous  appearance  as  compared 
with  the  "jury  mast"  used  in  the  treatment  by 
plaster-of-Paris  for  the  same  affection. 

Treatment  of  Dorsal  Disease.  Disease  of 
the  dorsal  vertebra?  extending  from  the  seventh  to 
the  twelfth  is  very  common.  The  mechanical  diffi- 
culties here,  as  well  as  in  the  lumbar  region,  are 
much  more  simple  than  those  involved  in  the  treat- 
ment of  the  upper  part  of  the  spine.  We  have 
here  as  a  firm  basis  for  our  support  the  pelvis  below, 
while  the  thorax  and  axilla?  afford  excellent  locations 
for  securing  fixation.  It  is  in  dorsal  disease  that 
the  best  results  are  often  obtained,  traumatism 
being  reduced  to  a  minimum  by  the  absence  of 
respiratory  and  other  movements,  which  conflict 
with  proper  support  in  the  cervico-dorsal  region. 
In  this  region  sufficient  leverage  can  be  obtained 
by  the  use,  of*  the  antero-posterior  support  without 
the  use  of  a  chin-piece.  It  is  necessary,,  however, 
that  the  anterior  support  or  apron  should  be  firm, 


POTT'S  DISEASE.  175 

and  it  is  often  beneficial  to  reinforce  this  by  the 
supplementary  means  of  corsets,  etc. 

Treatment  of  Lumbar  Disease.  Here  the 
difficulties  of  treatment  are  reduced  to  a  minimum, 
for  the  same  reasons  as  stated  in  speaking  of  lower 
dorsal  caries.  The  results  in  this  region  are  usually 
good,  exception  sometimes  taking  place  in  disease 
of  the  last  lumbar  vertebra.  At  times,  owing  to 
the  form  of  the  deformity,  it  is  difficult  to  prevent 
the  apparatus  from  pushing  or  slipping  upward. 
This  may  be  prevented  by  attaching  perineal  straps 
to  the  apron,  which  pass  between  and  are  fastened 
to  buckles  inserted  in  the  pelvic  band.  It  is  espe- 
cially in  the  lower  region  of  the  spine  that  any 
apparatus,  whether  of  steel  or  plaster,  providing 
proper  fixation  and  support,  gives  real  and  at  times 
instantaneous  relief  to  the  symptoms.  Care  must 
be  taken  here,  as  well  as  in  the  other  localities  af- 
flicted with  caries,  not  to  remove  the  splint  too  early. 

Treatment  oe  Complications.  Abscess  and 
paraplegia  are  the  two  most  common  complications 
of  caries  of  the  spine.  Of  the  former,  we  would 
simply  say  that  for  the  surgical  procedures  neces- 
sary for  their  relief  the  reader  is  referred  to  works 
on  surgery.  There  is,  however,  one  point  to  which 
we  wish  to  call  attention.  Clinical  experience  has 
taught  orthopedic  surgeons  that  the  course,  prog- 
ress, and  treatment  of  cold  abscesses  connected 
with  Pott's  disease  are  materially  affected  by  me- 
chanical treatment.  Where  good  support  of  the 
diseased  parts  is  given  we  are  sure  that  the  devel- 
opment of  abscesses  is  less  common,  their  course  is 


176  MEMOIR  OF  A.  S.  ROBERTS. 

more  benign,  and  in  many  instances  they  are  entirely 
absorbed.  Abscesses  of  this  nature  should  not  be 
opened  too  early,  and,  when  opened,  it  is  well  to  do 
so  in  a  position  suitable  for  thorough  drainage,  and 
under  rigid  antisepsis. 

Paraplegia,  as  has  been  already  stated,  has,  when 
caused  by  caries  of  the  spine,  a  spontaneous  dispo- 
sition to  recover.  Its  treatment  is  still  somewhat  a 
vexed  question.  Absolute  rest  in  the  recumbent 
posture,  with  efficient  support,  has  seemed  to  us  to 
have  been  of  most  benefit.  The  affection  being 
spastic  in  its  nature,  the  result  usually  of  a  direct 
irritation  of  the  cord,  electricity  in  any  form  would 
be  strongly  contraindicated.  Suspension  as  a 
means  of  treating  the  paraplegia  of  Pott's  disease 
has  not,  up  to  this  date,  been  sufficiently  tried  or 
recorded  to  give  any  idea  of  its  status  as  a  treat- 
ment for  this  form  of  paralysis. 

In  conclusion,  the  question  of  cessation  of  treat- 
ment is  of  practical  importance.  With  the  disap- 
pearance of  pain  and  the  non-increase  of  deformity, 
as  evidenced  by  repeated  measurement  and  compari- 
son of  the  patterns,  with  the  disappearance  of  reflex 
spasm,  allowing  of  free  motion  above  and  below  the 
deformity,  and  lastly  with  the  general  improvement 
in  the  condition  of  the  patient,  it  may  be  considered 
that  solidification  has  taken  place  and  that  the 
carious  process  has  been  arrested.  Relapses  may 
occur,  or  disease  may  appear  in  other  parts  of  the 
spine,  and  a  careful  watch  should  for  a  long  period 
of  time  be  kept  on  patients  who  have  been  the 
subjects  of  Pott's  disease. 


THE    SPINAL   ARTHROPATHIES 


12 


THE   SPINAL  APTHKOPATHIES. 

A    CLINICAL    REPORT   OF   SIX    CASES    OE   CHARCOT'S 

JOINTS. 


Case  I. — M.  K..,  male,  aged  forty-one,  referred  to 
the  New  York  Orthopedic  Dispensary  from  St. 
Luke's  Hospital  on  May  5,  1879.  Hereditary  his- 
tory unusually  good.  He  is  a  moderate  drinker. 
Health  excellent  until  manifestation  of  present  joint 
trouble.  Married,  and  the  father  of  five  healthy 
children. 

Condition  at  date  of  entry :  A  large  nodular 
tumor  was  found  over  the  left  hip-joint,  oval  in 
shape,  the  long  axis  of  which  corresponds  with  line 
of  Poupart's  ligament  (Fig.  44).  Transverse  diam- 
eter of  normal  limb  over  hip-joint,  22  inches ;  of 
affected  limb  at  same  point,  30J  inches.  No  mus- 
cular atrophy  detected  by  measurements  of  circum- 
ference. Left  limb  If  inches  shorter  than  its  fellow; 
measurements  made  from  the  umbilicus.  External 
iliac  fossa  of  left  side  filled  with  osteophytes,  which 
add  to  bulk  of  tumor.  The  ligamentous  structures 
about  the  joint  seem  entirely  destroyed ;  motion  of 
the  limb  abnormally  free  in  all  directions.  Head 
of  femur  probably  absorbed  or  greatly  atrophied. 
Limb  abducted  and  rotated  outward.     What  ap- 


180 


MEMOIR  OF  A.  S.  ROBERTS. 


pears  as  the  head  of  the  femur  is  anterior  to  its 
normal  position,  lying  under  a  "shed"  of  bone, 
built  out  from  the  pelvis,  which  covers  its  atrophied 
extremity  like   an    umbrella.      When   the   patient 


Fig.  44. 


flexes  the  limb,  the  upper  extremity  of  the  femur 
glides  forward  until  it  catches  under  this  "  shed  "  of 
provisional  bone,  which,  acting  as  a  fulcrum,  allows 
the  patient  to  flex  and  rotate  the  limb  with  ease. 


TEE  SPINAL  AB THR OPATHIES.  \  81 

A  thorough  examination  of  the  patient  for  evi- 
dence of  a  central  lesion,  revealed  the  absence  of 
numbness  of  limbs,  of  pain,  or  of  constricting  bands ; 
sensation  slightly  impaired  on  left  side.  On  right 
side,  reflex  action  increased  on  titillation  of  soles ; 
none  on  left.  No  tendon  reflex  in  either  limb. 
Sways  with  "  closed  eyes  test." 

Condition  eighteen  months  later:  The  patient 
presented  all  the  marked  symptoms  of  locomotor 
ataxia.  Two  years  from  date  upon  which  the  above 
notes  were  recorded  (May  5,  1879),  he  is  confined 
to  bed,  with  complete  loss  of  muscular  coordination. 

Remarks.  The  case  exhibits  an  arthropathy 
existing  four  and  a  half  years  prior  to  the  develop- 
ment of  active  tabetic  symptoms,  and  shows  a 
tendency,  from  early  stages,  to  the  formation  of 
osteophytes  about  the  joint,  with  early  atrophy  of 
the  upper  epiphysis  of  the  femur. 

At  no  time  during  the  progress  of  the  lesion  were 
there  developed  reflex  neural  symptoms  that  would 
point  to  joint  inflammation. 

The  joint  lesion  (swelling  and  tumefaction)  dimin- 
ished as  the  active  symptoms  of  ataxia  advanced. 
Provisional  callus  was  thrown  out  about  the  atro- 
phied extremity  of  the  femur  as  a  substitute  for  the 
destroyed  acetabulum. 

Case  II. — O.  P.,  male,  aged  forty-four.  Regis- 
tered as  an  out-patient  in  the  New  York  Orthopedic 
Dispensary  on  January  29,  1879.  The  following 
notes  were  recorded : 

Hereditary  History.  Parents  living  and 
healthy ;  one  brother  died  of  phthisis.     Patient  is 


182 


MEMOIR  OF  A.  S.  ROBERTS. 


married  ;  has  three  children,  two  in  excellent  health, 
the  third  has  an  intrapelvic  abscess  (subsequently 
died  of  amyloid  degeneration  of  the  kidneys).  Pa- 
tient has  had  to  work  very  hard,  with  considerable 
mental  anxiety ;  no  other  known  cause  for  present 
disease. 

Fig.  45.   * 


The  left  knee  and  ankle  (Fig.  45)  are  enlarged, 
the  latter  more  so  relatively  than  the  knee.  The 
patient  states  that  seven  years  ago,  while  working, 
a  heavy  box  fell  upon  him,  injuring  the  ankle.  The 
joint  became  swollen,  and  he  was  "laid  up  for  two 
months."  lie  recovered,  and  suffered  no  inconven- 
ience for  one  year;  the  swelling  again  returned  in 


THE  SPINAL  ARTHROPATHIES.  183 

the  same  ankle  and  involved  the  entire  leg.  At 
this  time  he  was  incapacitated  from  work  for  three 
months ;  recovered,  and  has  had  no  active  joint 
symptoms  since.  Has  never  had  an  abscess  about 
the  joint. 

The  urgent  symptoms  at  present  examination  are 
those  of  locomotor  ataxia.  He  cannot  walk  with- 
out staggering,  and  when  attempting  to  do  so  in 
the  dark,  or  with  closed  eyes,  falls.  Suffers  from 
ataxic  pains  in  the  right  leg  and  arm.  Is  uncertain 
in  guiding  his  finger  to  the  tip  of  his  nose,  with  eyes 
closed,  or  in  putting  his  heel  on  a  designated  spot. 
Sensation  impaired  in  right  hand  and  arm ;  has  diffi- 
culty in  buttoning  his  coat  with  that  hand.  "When 
standing  or  walking  in  his  bare  feet,  he  feels  as 
though  he  were  on  cushions ;  vision  unimpaired 
(eye-ground  not  examined). 

On  February  4, 1879,  Dr.  Cloves  Adams  saw  the 
patient  in  consultation,  and  thought  him  to  be  suf- 
fering from  locomotor  ataxia  in  the  third  stage,  with 
osseous  changes  in  left  ankle  and  synovitis  of  both 
knees. 

The  patient  returned  to  the  dispensary  in  Sep- 
tember of  the  same  year,  with  a  marked  elastic 
swelling  of  the  right  elbow-joint  (Fig.  46). 

A  year  later  (November,  1880),  he  was  referred 
to  the  clinic  of  Dr.  E.  C.  Seguin.  He  again  applied 
to  the  Orthopedic  Dispensary  on  February  14, 1881. 
The  ataxic  symptoms  had  advanced ;  he  walked 
with  extreme  difficulty.  The  condition  of  the  joints 
remained  about  the  same  as  when  last  examined, 
now  four  months  ago. 


184 


MEMOIR  OF  A.  S.  ROBERTS. 


During  November  (1881)  the  patient  was  criti- 
cally examined  by  Dr.  S.  Weir  Mitchell,  and  pro- 
nounced to  be  in  the  third  stasre  of  locomotor  ataxia, 


Fig.  46. 


with  spinal  arthropathies  of  the  right  elbow  and 
left  ankle-joints.  It  was  noted  that  the  circumfer- 
ence of  the  elbow  tumor  had  materially  diminished 
since  the  last  measurements  were  recorded  (decrease 
of  two  and  a  half  inches). 


THE  SPINAL  ARTHROPATHIES.  185 

Remarks.  The  joint  enlargements  in  this  patient 
presented  three  characteristic  peripheral  ataxic  con- 
ditions : 

1.  At  the  knee-joint  synovial  irritation,  indicated 
by  the  physical  signs  of  a  chronic  synovitis,  although 
at  no  time  during  its  course  was  there  evidence  of 
inflammation. 

2.  A  characteristic  doughy,  nodular,  ataxic  joint 
tumor  of  the  elbow,  largely  composed  of  osteophytes 
and  excessive  synovial  secretion. 

3.  Hypertrophy  of  the  lower  epiphyses  of  the 
tibia  and  fibula,  with  but  slight  synovial  irritation. 

The  peripheral  manifestations  at  the  knee  and 
ankle  accompanied  the  earlier  symptoms  of  ataxia  ; 
the  elbow  tumor  entered  abruptly  upon  the  second 
stage  of  the  sclerosis.  I  am  indebted  to  my  friend 
Dr.  Newton  M.  Shaffer,  of  New  York,  for  the 
privilege  of  reporting  the  above  notes. 

Case  III. — J.  H.,  male,  aged  forty-five ;  was 
admitted  to  my  wards  in  the  Philadelphia  Hospital 
on  April  3,  1883.  The  following  notes  were  re- 
corded :  A  vigorous,  well- nourished  man,  with  little 
personal  knowledge  of  his  family  or  their  history. 
Knew  his  parents  lived  to  advanced  age,  but 
thought  both  of  his  brothers  had  died,  and  likewise 
two  sisters.  Acknowledged  to  being  strongly  ad- 
dicted to  the  use  of  alcohol.  He  thought  that  his 
present  trouble  arose  from  a  "  dissipated  life  and 
constitutional  syphilis." 

Two  years  ago,  after  a  debauch,  his  attention 
was  directed  to  painful  swelling  of  his  right  great 
toe.     This  lasted  a  few  days,  and  as  the  pain  and 


186  MEMOIR  OF  A.  S.  ROBERTS. 

swelling  of  the  toe  subsided,  the  right  ankle-joint 
enlarged.  This  swelling  slowly  and  painlessly  in- 
creased, and  three  months  from  its  onset,  the  same 
condition  appeared  in  the  left  ankle-joint.  Without 
especial  discomfort  to  the  patient,  this  joint  enlarged. 
He  continued  drinking  to  excess,  and  was  admitted 
to  the  hospital  in  a  state  of  chronic  alcoholism. 

An  examination  two  weeks  after  admission,  when 
all  traces  of  alcoholism  had  subsided,  gave  evidence 
by  the  following  facts  of  a  central  lesion :  He  had 
suffered  from  constricting  pains  about  the  abdomen, 
and  occasional  darting  pain  in  the  region  of  the  hips 
and  thighs  for  the  past  year.  He  also  experiences 
considerable  difficulty  in  walking,  especially  at 
night.  At  present  he  has  a  staggering  gait.  Ab- 
sence of  patellar  reflex  in  both  limbs ;  sways  and 
falls  with  "  closed  eyes  test,"  and  has  difficulty  in 
finding  tip  of  nose  with  forefinger  when  eyes  are 
closed. 

The  metatarsophalangeal  articulation  of  the  right 
great  toe  is  anchylosed.  Both  ankle-joints  are  en- 
larged, apparently  by  a  diffuse  hypertrophy  of  the 
epiphyses  of  tibia  and  fibula.  This  increase  has 
almost  doubled  their  normal  circumference.  The 
subcutaneous  tissues  are  slightly  cedematous.  The 
capsules  of  ankle-joints  are  distended  and  elastic. 

"When  first  admitted,  the  tissues  about  the  ankles 
and  legs  were  swollen,  presenting  the  appearance  of 
diffuse  cellulitis.  This  subsided  in  a  few  days  from 
rest  and  local  treatment. 

My  colleague,  Dr.  C.  K.  Mills,  saw  the  patient 
with   me  in  consultation,  and  confirmed  the  diag- 


THE  SPINA  L  AB  THB  OP  A  THIES.  187 

nosis  I  had  made — of  posterior  spinal  sclerosis,  with 
accompanying  arthropathies  at  ankle-joint. 

Remarks.  The  joint  hypertrophy  had  preceded 
any  active  symptoms  of  ataxia.  The  character  of 
the  joint  enlargement  was  that  of  bony  hypertrophy, 
without  a  tendency  to  the  formation  of  osteophytes 
or  to  nodular  irregularity  of  contour. 

The  possibility  of  rheumatism  or  malignant  dis- 
ease was  considered  and  dismissed.  A  thorough 
physical  examination  failed  to  detect  any  of  the 
characteristic  reflex  neural  symptoms  of  epiphyseal 
osteitis. 

The  history  of  the  progress  and  course  of  the 
ankle-joint  hypertrophy,  together  with  the  evidence 
of  a  central  lesion  and  the  negative  physical  signs 
of  local  joint  inflammation,  all  confirmed  the  diag- 
nosis of  an  arthropathy  of  spinal  origin. 

Case  TV. — Dr.  A.  A.  Y.,  male,  aged  sixty-five, 
resident  of  Hammonton,  N".  J.  Examined  the 
patient  with  Dr.  S.  Weir  Mitchell  on  January  16, 
1885.  For  the  substance  of  the  following  notes  I 
am  indebted  to  Dr.  Woodnut : 

Hereditary  history  of  patient  excellent.  He  had 
always  been  strong  and  healthy  during  youth  and 
up  to  1865,  though  a  hard-working  farmer.  An 
army  life,  and  three  years  of  extreme  exposure  prior 
to  the  close  of  the  war,  found  him  suffering  in  1865 
from  sharp,  wandering  pains  in  the  upper  and  lower 
extremities ;  never  noticed,  however,  in  the  articu- 
lations. Loss  of  power  followed  in  the  right  leg. 
Three  years  later  suppurative  arthritis  attacked  the 
metatarso-phalangeal  articulation  of  the  right  great 


188  MEMOIR  OF  A.  S.  ROBERTS. 

toe,  and  last  phalanx  of  left  ring  finger,  sequestra 
coming  away  in  each  instance. 

During  1870  the  patient  first  noticed  an  cedema- 
tous  swelling  of  the  right  elbow ;  following  shortly 
upon  this,  the  wrist-joint  of  the  same  arm  gradually 

Fig.  47. 


and  painlessly  enlarged.  Then  a  distention  of  the 
capsule  of  the  right  knee-joint  succeeded.  The 
enlargement  of  the  latter  articulation  was  more 
rapid  than  either  the  wrist  or  elbow.     Rheumatic 


THE  SPINAL  ARTHROPATHIES.  189 

pains  in  the  joints  accompanied  the  swelling  and 
deformity. 

The  left  limb  has  been  comparatively  exempt 
from  pain.  Recently,  however,  the  capsule  of  the 
knee-joint  has  become  distended  and  elastic.  The 
elbow-tumor  has  diminished  somewhat  in  circum- 
ference during  the  past  four  years. 

During  the  past  year  the  distal  phalanx  of  the 
right  index  finger  has  gradually  atrophied  without 
inflammation,  and  is  now  entirely  wanting.  The  nail 
and  finger  end  are  normal,  though  somewhat  short- 
ened. Pain  at  present  is  chiefly  in  both  feet,  parox- 
ysmal and  erratic,  often  attacking  corresponding 
points  on  the  legs. 

At  present  the  right  elbow  and  knee-joint  en- 
largements (Fig.  47)  exhibit  an  irregular  nodulated 
hypertrophy,  bearing  no  resemblance  to  normal  joint 
outline,  and  consisting  chiefly  of  osteophytes  and 
abnormal  increase  of  synovial  fluid.  Motion  is 
preternaturally  free  in  all  directions ;  structure  of 
joints  apparently  entirely  destroyed. 

Remarks.  The  joint  lesions  first  appeared  in 
this  patient  after  ataxia  had  become  established. 
The  appearance  of  the  affected  elbow  and  knee  is 
that  of  an  enormous  nodular  hypertrophied  mass  of 
bone,  doubling  their  normal  circumference,  asso- 
ciated with  synovial  distention  of  the  capsule. 
Osteophytes  readily  movable  within  the  capsule, 
and  varying  in  size  from  a  pigeon's  egg  to  that  of 
a  turkey. 

The  atrophy  of  the  distal  phalanx  of  the  right 
index  finger  is  especially  to  be  noted.    It  is  the  first 


190 


MEMOIR  OF  A.  S.  ROBERTS. 


instance  of  complete  absorption  of  the  diaphysis  of 
bone  that  I  have  had  an  opportunity  of  observing. 

Case  V. — "W.  H.  McC,  male,  aged  thirty-eight, 
married.  Admitted  to  the  Orthopedic  Dispensary 
of  the  University  Hospital  in  July,  1883. 


Hereditary  history  excellent ;  no  evidence  could 
be  obtained  of  articular  disease,  rheumatism,  or 
phthisis  in  any  member  of  his  family.  He  pre- 
sented at  the  date  of  examination  the  appearance  of 
a  healthy  well-nourished  man.     Has  always  worked 


THE  SPINA  L  AR  THE  OP  A  THIES.  191 

industriously  at  his  trade  of  plumber.  A  moderate 
drinker.  He  had  constitutional  evidence  of  syphilis, 
following  a  chancre  contracted  in  1863. 

The  patient  attributes  the  present  enlargement 
of  the  right  ankle-joint  to  an  injury  received  while 
working  in  a  cramped  position.  Following  this 
strain  the  ankle  became  suddenly  discolored  and 
swollen,  bursting  the  buttons  from  his  shoes.  He 
was  incapacitated  for  work  during  the  succeeding 
four  days ;  at  the  end  of  a  week  the  discoloration 
and  swelling  had  about  disappeared.  His  attention 
was  then  first  directed  to  a  bony  enlargement  of  the 
right  ankle-joint.  This  slowly  and  painlessly  in- 
creased in  size  without  any  appreciable  interference 
in  locomotion.  At  present  examination  the  en- 
largement resembles  a  simple  hypertrophy  of  the 
lower  epiphyses  of  the  tibia  and  fibula  (Fig.  48). 
The  outline  of  the  joint  is  globular,  with  slight 
elasticity  of  capsule.  No  pain  or  reflex  muscular 
spasm. 

Record  of  Spinal  Symptoms.  Complains  of 
darting  pains  about  hips.  Has  difficulty  in  walking 
at  night.  Sways  with  closed  eyes.  Complete 
absence  of  patellar  reflex  on  both  sides.  Dr. 
Horatio  C.  Wood  saw  him  with  me  in  October  of 
1833,  and  pronounced  him  ataxic. 

KemaPlKS.  This  case  presents  an  arthropathy 
that  apparently  followed  a  direct  traumatism  to  the 
affected  joint.  From  careful  interrogation,  I  deter- 
mined that  the  acute  swelling  and  ecchymosis 
resulted  from  the  rupture  of  a  varicose  vein,  inas- 
much as  these  were  numerous  and  greatly  engorged 


192  MEMOIR  OF  A.  S.  ROBERTS. 

about  the  affected  ankle.  This  first  attracted  his 
attention  to  the  ankle,  the  deeper  bony  growth 
being  detected  when  the  active  symptoms  of  sub- 
cutaneous swelling  had  subsided. 

The  hypertrophy  of  the  joint  has  increased  the 
circumference  four  and  a  half  inches  over  its 
fellow. 

Case  YI. — A  specimen  of  shoulder-joint  arthrop- 
athy, lately  removed  at  an  autopsy  held  upon  the 
body  of  a  well-marked  ataxic,  has  been  referred  to 
me  by  Dr.  S.  Weir  Mitchell,  to  embody  in  this 
report.  The  joint  had  become  suddenly  and  pain- 
lessly enlarged  in  the  later  stages  of  the  central 
lesion.  It  presented  ante  mortem  all  the  char- 
acteristic symptoms  of  a  tabetic  arthropathy  : 
distention  of  the  capsule,  abnormal  mobility,  and 
the  presence  of  osteophytes.  The  joint,  upon  ex- 
amination, presented  the  following  structural 
changes : 

1.  Cartilage  covering  head  of  humerus  eroded; 
that  upon  glenoid  cavity  irregularly  thickened. 

2.  Anterior  margin  of  glenoid  cavity  worn  away, 
allowing  the  head  of  bone  to  rest  in  position  of 
forward  dislocation. 

3.  Osteophytes  abundant  about  junction  of  cap- 
sule with  anatomical  neck.  Marked  relaxation  of 
ligamentous  structures,  and  distention  of  capsule. 

4.  General  hypertrophy  of  epiphysis,  somewhat 
nodular  at  margins.     Evidences  of  hydrarthrosis. 

The  practical  deductions  to  be  drawn  from  a 
clinical  study  of  the  above  somewhat  anomalous 
cases,  may  be  briefly  summarized  as  follows : 


THE  SPINAL  ARTHROPATHIES.  193 

Period  of  Development.  1.  The  tabetic  ar- 
thropathies may  occur  independently,  or  precede  the 
active  symptoms  of  locomotor  ataxia. 

2.  They  occasionally  develop  suddenly,  late  in 
the  course  of  a  posterior  spinal  sclerosis. 

Nature  of  Lesions.  The  peripheral  expression 
of.  central  nerve  irritation  is  characterized  by  the 
following  changes  found  in  the  structure  of  the 
various  articulations. 

1.  A  chronic  asthenic  hyperemia  of  the  synovial 
membranes ;  a  hydrarthrosis. 

2.  An  interstitial  atrophy  of  the  epiphyses. 

3.  A  fungous  or  rarefying  epiphyseal  hypertrophy. 

4.  The  formation  of  osteophytes  and  bony  stalac- 
tites. 

These  various  joint  lesions  characteristic  of  the 
spinal  arthropathies  may  exist  separately ;  but  are 
usually  combined  in  the  same  subject. 

Differential  Diagnosis.  They  may  be  readily 
distinguished  from  the  common  inflammatory  dis- 
eases of  the  epiphyses  by  the  total  absence  of  the 
reflex  neural  phenomena — i.  e.,  of  pain,  both  reflex 
and  local,  the  apprehensive  state  regarding  joint 
movements,  and  the  reflex  or  tetanic  spasm  of  the 
muscles,  always  associated  with  joint  osteitis.  Ab- 
scess is  never  directly  associated  with  the  arthrop- 
athies, unless  incident  upon  direct  traumatism. 

They  are  more  difficult  to  differentiate  from 
malignant  affections  of  the  articulations ;  but  a 
careful  inquiry  into  the  history  and  course  of  the 
lesion,  and  the  presence  or  absence  of  central  dis- 
turbance, are  our  most  reliable  guides. 

13 


194  MEMOIR  OF  A.  S.  ROBERTS. 

Course.  The  progress  of  the  arthropathies  is 
essentially  chronic.  Occurring,  not  infrequently, 
early  in  the  history  of  the  tabetic  lesion,  they  slowly 
increase,  with  occasional  exacerbations,  and  years 
elapse  before  fully  matured.  Their  course  is  self- 
limiting,  though  never  reparative. 


THE   ETIOLOGY,  MORBID  ANATOMY,  VARIETIES, 
AND  TREATMENT 


OF 


CLUB-FOOT 


CLUB-FOOT. 


LECTURE   I. 


Gentlemen  :  Every  observant  person,  whether 
within  or  without  the  profession  of  medicine,  must 
be  impressed  with  the  prevalence  of  various  deform- 
ities in  individuals  of  the  human  family,  and  their 
very  existence  must  cause  him  to  reflect  upon  the 
nature  of  their  being,  their  chronic  and  progressive 
character,  and  the  apparent  difficulty  of  arresting 
them.  Much  of  this  has  been  due  to  lack  of  knowl- 
edge of  the  mechanical  factors  which  enter  into  their 
etiology,  and  the  very  general  neglect  the  subject 
of  malformations  has  received,  from  an  educational 
stand-point,  in  our  medical  schools.  Though  twenty- 
five  years  have  elapsed  since  the  establishment  of 
orthopedic  surgery  as  a  legitimate  special  branch  of 
surgical  art,  its  science  and  practice,  noticeably  in 
this  city,  are  permitted  to  occupy  a  very  subordi- 
nate position,  and  its  principles  practically  are 
untaught.  In  this  clinic,  which  will  initiate  the 
course  of  lectures  upon  orthopedic  surgery  in  the 
Philadelphia  Hospital,  which  it  will  be  my  privilege 
to  deliver  before  you  this  spring,  no  better  subject 

1  Clinical  Lectures  on  Orthopedic  Surgery,  delivered  at  the  Phila- 
delphia Hospital. 


198  MEMOIR  OF  A.  S.  ROBERTS. 

could  be  chosen  than  one  descriptive  of  club-foot,  a 
condition  which  you  will  frequently  meet  in  prac- 
tice, and  of  which  many  examples  may  be  constantly 
observed  in  the  nervous,  obstetrical,  and  surgical 
wards  of  this  hospital. 

We  may  define  club-foot,  or  talipes,  which  latter 
designation  was  first  employed,  about  thirty  years 
ago,  by  William  J.  Little,  of  London,  as  a  deform- 
ity of  the  foot,  caused  by  paralysis,  permanent 
spasm,  or  structural  shortening  of  the  muscles,  con- 
tractions of  fasciae  or  ligaments,  and  resulting  in 
an  alteration  of  the  normal  relations  of  the  tibio- 
astragaloid  articulation,  or  between  the  bones  of 
the  tarsus  proper.  Under  the  generic  term  club- 
foot, or  talipes,  we  include  all  deformities  of  the 
foot  which  occur  on  an  antero-posterior  or  trans- 
verse plane,  and  which  are  characterized  by  flexion, 
extension,  inversion  or  eversion. 

To  obtain  a  clear  conception  of  the  deformities 
under  consideration,  it  is  best  to  divide  the  foot 
into  an  anterior  and  a  posterior  portion,  the  former, 
the  "^>es,"  or  foot  proper,  and  the  latter,  the  "  talus" 
or  ankle.  These  portions  articulate  at  Chopart's 
joint,  which  is  formed  by  the  astragalus  and  os 
calcis  behind,  and  the  scaphoid  and  cuboid  in 
front.  For  purposes  of  clinical  study,  club-foot  is 
conveniently  separated  into  two  classes,  composed 
of  the  simple  and  the  compound  forms.  Of  the 
former  there  are  four  varieties,  two  between  the 
tibia  and  foot,  namely,  equinus,  in  which  the  heel  is 
raised,  the  foot  being  held  in  the  extended  posi- 
tion, the  patient  walking  upon  the  ball  of  the  foot; 


CLUB-FOOT. 


199 


and  calcaneus,  its  opposite,  in  which  the  patient 
walks  upon  the  heel,  the  foot  being  drawn  into  the 
position  of  flexion.  There  are  also  two  lateral  de- 
formities :  varus,  in  which  the  internal  border  of  the 
foot  is  elevated,  the  sole  directed  inward,  and  the 
anterior  portion  of  the  foot  adducted ;  and  valgus, 
its  opposite,  in  which  the  outer  side  of  the  foot  is 
raised  and  the  sole  everted.  Any  combination  of 
these  simple  varieties  will  present  compound  forms, 
such  as  talipes  equino-varus,  equino-valgus,  calcaneo- 
valgus,  etc. ;  some  authors  have  added  others :  for 
instance,  talipes  cavus,  in  which  the  arch  of  the  foot 
is  increased,  and  talipes  planus,  or  spurious  valgus, 
in  which  the  foot  is  flattened,  the  arch  resting  upon 
the  ground.  Recently,  Shaffer,  of  ]S"ew  York,  under 
the  title  non-deforming  club-foot,  has  described  a 
class  of  cases  in  which  there  is  little  or  no  deformity, 
but  which  are  very  important  on  account  of  the 
inconvenience  they  occasion  the  sufferer,  and  the 
results  to  which  they  give  rise,  coupled  with  the 
liability  of  being  overlooked,  unless  care  be  taken 
in  the  examination  of  the  patient. 

The  varieties  of  club-foot  may  be  classified  as 
follows : 

Table  No.  I. 


'  Simple. 


Varieties  .    \  Compound 


f  Anteroposterior 

J  Equinus. 
j  Calcaneus 

(  Lateral 

f  Varus. 
j  Valgus. 

f  Equino- 

f  Varus. 
I  Valgus. 

(  Calcaneo-  . 

f  Varus. 
{  Valgus. 

( Cavus. 
(_  Other  forms.  <  Planus. 

Non-deformins:. 


200 


MEMOIR  OF  A.  S.  ROBERTS. 


As  previously  mentioned,  these  simple  forms,  or 
their  combinations,  constitute  the  deformities  which 
you  will  meet  with,  and  a  knowledge  of  their  rela- 
tive frequency  is  of  interest  and  importance.  Much 
difficulty  is  experienced  in  the  investigation  of  this 
subject,  owing  to  the  difference  in  nomenclature 
employed  by  various  authors,  similar  conditions 
being  spoken  of  under  different  names.  Duval  has 
recorded  1000  cases,  of  which  574  were  congenital ; 
364  of  these  were  in  males,  and  210  in  females.  His 
statistics  as  to  relative  frequency  are  valuable,  and 
are  as  follows : 


Table  No.  II. 

Cases. 

Boys. 

Girls 

Equinus  and  equino-varus       .     417 

215 

202 

Varus 532 

302 

230 

Valgus 22 

14 

8 

Calcaneus         ....        9 

6 

3 

Extreme  calcaneus  ...      20 

13 

7 

Totals        ....  1000 

550 

450 

I  have  compiled  the  following  statistics,  shown  in 
Table  No.  III.,  from  the  records  of  the  New  York 
Orthopedic  Hospital,  and  the  Orthopedic  Dispen- 
sary of  the  University  of  Pennsylvania : 


Table  No. 

in. 

Congenital. 

Acquired 

Equinus 5 

87 

Calcaneus    . 

3 

31 

Varus 

73 

66 

Valgus 

29 

236 

Equino-varus 

95 

68 

Equino-valgus     . 

3 

9 

Calcaneo-varus   . 

(i 

2 

Calcaneo-valgus  . 

5 

34 

Totals  .... 

213 

533 

CLUB-FOOT. 


201 


Lannelongue  has  collected  the  statistics  of  the 
Maternity  Hospital  (Paris),  covering  a  period  of 
ten  years,  from  1858  to  1867,  inclusive.  In  15,229 
births,  8  children  were  born  with  club-foot,  a  pro- 
portion of  about  1  case  in  1963  births. 

The  condition  may  be  present  as  a  congenital  or 
an  acquired  deformity,  and  the  relative  frequency 
of  the  two  forms  may  be  seen  by  reference  to  Table 
No.  III.,  from  the  cases  treated  in  the  ~New  York 
Orthopedic  Hospital,  and  the  Orthopedic  Dispen- 
sary of  the  University  of  Pennsylvania,  in  which 
are  recorded  746  cases,  of  which  213  were  congeni- 
tal, and  533  acquired.  Tamplin's  deductions,  shown 
in  Table  ~No.  IV.,  covering  764  cases  of  congenital 
talipes,  show  the  relative  frequency  to  be  as  follows  : 


Table  No.  IV. 

Congenital. 

Talipes 

varus 

688  cases 

« 

valgus 

42      " 

u 

calcaneus 

19      " 

(1 

varus  of  one 

foot  and  valgus  of  the 

other    . 

15      " 

Total 

Acquired. 

764      " 

Talipes 

equinus    . 

401  cases 

a 

valgus 

181      " 

a 

equino-varus 

162      " 

i( 

calcaneus  and  calcaneo-valgus 

110      " 

(< 

equino-valgus          .... 

80      " 

11 

varus 

60      " 

a 

varus  of  one 

foot  and  valgus  of  the 

other    . 

Total 

. 

5      " 
999      " 

202  MEMOIR  OF  A.  S.  ROBERTS. 

Adams  states  the  proportion  between  the  con- 
genital and  acquired  forms  to  be  as  2 :  3,  and  the 
tables  already  referred  to  show  the  large  prepon- 
derance of  cases  in  which  the  deformity  has  been 
acquired.  Giving  due  weight  to  the  statistics  which 
have  been  alluded  to,  we  may  conclude  that  club-foot 
occurs  more  frequently  in  males  than  in  females; 
that  cases  in  which  inversion  and  adduction  of  the 
foot,  either  accompanied  or  not  by  elevation  of  the 
heel,  or  the  varus  types,  are  oftener  met  with,  and 
that  the  right  foot  is  more  frequently  deformed  than 
the  left,  but  that  many  more  cases  of  double  club- 
foot occur  than  of  single ;  and  that  the  primitive 
forms,  pure  equinus,  calcaneus,  varus  or  valgus, 
are  rare. 

The  etiology  of  congenital  talipes  is  veiled  in 
obscurity.  The  difficulty  of  studying  pathological 
changes  occurring;  during  intra-uterine  life  is  self- 
evident,  as  the  foetus  cannot  be  subjected  to  any 
direct  scientific  method  of  investigation.  Compara- 
tive physiology,  embryology,  and  the  changes  and 
diseases  which  occur  subsequently  to  birth,  give  us 
data  of  comparative  value,  but  all  such  investiga- 
tions have  resulted  in  much  speculation,  many 
theories,  and  but  few  facts.  The  theory  that  dis- 
eases which  produce  the  acquired  forms  have  their 
prototypes  during  intra-uterine  existence  has  its  sup- 
porters, notably  Little.  But  microscopical  research 
has  not  yet  shown  the  existence  of  changes  in  the 
foetal  brain  and  spinal  cord  analogous  to  those  found 
in  cases  of  the  acquired  paralytic  forms.  Volun- 
tary   muscular   control    is    retained    in    congenital 


CLUB-FOOT.  203 

cases,  while  it  is  lost  in  the  acquired  varieties  re- 
ferred to,  and  the  electrical  reactions  are  markedly 
different ;  so  that  this  theory  has  no  foundation  to 
rest  upon,  except  the  similarity  in  the  appearance  of 
the  deformities. 

Hereditary  influence,  with  its  transmission  of 
peculiarities  of  face  and  form,  of  various  tendencies, 
of  traits  of  character,  etc.,  has  some  weight  as  an 
etiological  factor. 

Another  theory  of  causation  is  that  of  arrest  of 
development,  and,  although  cases  occur  in  which 
coexisting  deformities,  such  as  spina  bifida,  hare- 
lip, cleft  palate,  etc.,  are  also  present,  the  feet  show 
no  evidence  of  arrest  of  development,  the  only  alter- 
ation being  that  of  the  direction  of  the  planes  of 
the  feet  which  is  characteristic  of  the  deformity. 
Adams  and  Hiiter,  it  is  true,  have  described  changes 
in  the  bones  involved,  consisting  of  alteration  of 
form  and  relative  position  of  articulating  facets, 
but  these  changes  are  by  no  means  constant,  and 
whether  they  be  causative  or  secondary  to  the 
altered  relation  of  the  bones  is  a  matter  regarding: 
which  there  is  much  difference  of  opinion.  Person- 
ally, I  incline  to  the  latter  view,  although  the  theory 
has  many  eminent  supporters,  including  A.  Liicke. 

The  theory  which  has,  perhaps,  the  greatest  num- 
ber of  votaries  is  that  which  ascribes  to  abnormal 
intra-uterine  pressure,  and  deficiency  of  amniotic 
fluid,  the  influence  productive  of  club-foot,  the 
foot  being  permanently  fixed  in  the  abnormal  posi- 
tion during  intra-uterine  life.  Although  numbering 
among  its  supporters   such  names   as  Volkmann, 


204  MEMOIR  OF  A.  S.  ROBERTS. 

Kocher,  Bauga,  and  Parker,  I  do  not  think  the 
assumption  tenable,  for  the  following  reasons : 
AVere  this  deformity  the  result  of  pressure,  it  is 
reasonable  to  believe  that  in  many  cases  deformity 
of  other  members  would  coexist,  having  been  ex- 
posed to  the  same  pressure-influence ;  such,  how- 
ever, is  not  the  case,  combinations  of  this  kind 
being  of  rare  occurrence.  Again,  in  children  who 
have  been  born  with  club-foot,  and  in  which  the 
mother  had  previously  given  birth  to  several  health}^ 
children,  no  appreciable  difference  in  the  quantity 
of  amniotic  fluid  discharged  during  the  various 
labors  can  be  made  out.  Further,  I  have  recently 
seen  a  case  of  double  equino-varus  in  a  twin,  the 
other  child  showing  no  deformity  whatever. 

Dr.  H.  W.  Berg,  of  New  York,  in  a  series  of 
investigations  which  are  commendable  for  their 
originality,  ascribes  congenital  equino-varus  to  a 
failure  of  rotation  during  intra-uterine  existence. 
In  his  studies  at  the  New  York  Hospital  and 
Wood's  Museum  at  Bellevue  Hospital,  he  has  fol- 
lowed the  changes  which  occur  in  the  position  of 
the  lower  extremities  at  different  periods  of  foetal 
life.  At  first,  the  entire  leg  is  rotated  outward,  and 
the  feet  are  in  a  position  of  marked  varus,  and, 
subsequently,  of  equino-varus.  Later,  rotation  in- 
ward takes  place,  gradually  diminishing  the  amount 
of  varus ;  but  even  after  this  rotation  has  been 
completed  some  varus  remains,  and,  in  a  very  slight 
degree,  is  the  normal  position  of  the  foot  in  the 
new-born.  Dr.  Berg  found,  in  some  instances, 
equinus  to  be  present  in  foetuses  of  two,  three,  and 


CLUB-FOOT.  205 

four  months,  the  condition  disappearing  in  the  pro- 
cess of  normal  growth,  and  he  reaches  the  conclu- 
sion that  in  early  foetal  life  equino-varus  or  varus 
is  physiological,  and  that  its  disappearance  is  coin- 
cident and  keeps  pace  with  the  normal  rotation  of 
the  limb.  When,  from  any  cause,  rotation  is  re- 
tarded or  arrested,  club-foot  results. 

To  summarize  the  theories  to  which  I  have 
alluded,  and  which  constitute  the  principal  ones 
advanced  in  explanation  of  the  causes  of  congenital 
talipes,  I  have  reduced  them  to  the  following :  that 
which  would  ascribe  club-foot  to  pathological 
changes  occurring  in  the  foetus,  similar  to  post- 
natal diseases ;  that  which  assumes,  as  a  cause,  the 
action  of  mechanical  forces  upon  the  child  in  utero ; 
then  the  theory  of  heredity,  with  its  influences  but 
little  understood ;  the  theory  of  arrest  of  develop- 
ment ;  and,  lastly,  the  theory  promulgated  by  Dr. 
Berg,  which  would  make  club-foot  dependent  upon 
the  absence  or  retardation  of  rotation.  The  last 
mentioned  possesses  the  merit  of  being  demonstra- 
ble by  embryological  research,  and  in  the  present 
state  of  our  knowledge  it  has,  in  my  opinion,  greater 
claims  to  recognition  than  those  which  are  based 
upon  similarity  of  post-natal  conditions,  or  those 
which  rest  upon  even  a  more  fanciful  basis. 

Turning  our  attention  now  to  the  consideration 
of  the  etiology  of  acquired  talipes,  we  do  not  find 
the  path  of  investigation  beset  with  the  difficulties 
we  met  with  in  the  study  of  the  causation  of  the 
congenital  types.  We  may  divide  the  causes  into 
six  groups  :  1.  Infantile  spinal  paralysis.    2.  Spastic 


206  MEMOIR  OF  A.  S.  ROBERTS. 

contractions  due  to  an  irritative  lesion  of  the  spinal 
cord.  3.  Contraction  of  aponeuroses.  4.  Trauma- 
tism.    5.  Rhachitis.     6.  Hysteria. 

By  far  the  greater  number  of  cases  of  acquired 
talipes  are  due  to  infantile  spinal  paralysis — "  polio- 
myelitis anterior."'  This  is  essentially  a  disease  of 
childhood,  usually  occurring  at  the  period  of  denti- 
tion, its  invasion  being,  as  a  rule,  sudden,  marked 
by  fever,  gastro-intestinal  disturbance,  sometimes 
ushered  in  by  a  convulsion,  and  immediately  fol- 
lowed by  muscular  paralysis,  more  or  less  extensive. 
Recovery  follows  rapidly  in  many  of  the  muscles 
affected,  but  is  rarely,  if  ever,  complete,  a  certain 
amount  of  residual  paralysis  remaining  permanently, 
in  one  or  both  of  the  lower  extremities.  Atrophic 
changes  now  take  place,  and  are  characterized  by 
wasting  of  the  muscles  of  the  limb,  loss  of  electro- 
contractility,  especially  to  the  faradic  current;  later 
by  reaction,  when  stimulated  by  galvanism,  charac- 
teristic of  degenerative  change,  and  deformity,  of 
which  the  most  frequent  is  club-foot. 

It  has  been  thought  that  the  deformity  in  these 
cases  was  due  to  the  loss  of  equilibrium  between 
the  muscles  of  the  limb ;  one  set  being  paralyzed, 
their  antagonists  drawing  the  foot  into  the  deformed 
position;  but  Hitter  has  shown  that  the  weight  of 
the  limb,  in  the  position  assumed  in  paralysis,  is  the 
cause  of  contractions,  and  that  these  were  due  to 
atrophy  and  arrest  of  growth,  and  were  not  in  any 
sense  muscular.  In  some  cases,  resulting  from 
poliomyelitis,  the  deformity  is  due  entirely  to  the 
force  of  gravity,  the  foot  dropping  into  the  position 


CLUB-FOOT.  207 

of  equinus,  and  the  anterior  portion  being  adducted 
by  its  own  weight.  In  these  cases  there  is  little,  if 
any,  contraction,  and  the  deformity  is  readily  reduced 
by  manual  pressure,  but,  of  course,  returns  imme- 
diately upon  the  removal  of  the  hand.  Volkmann, 
also,  has  directed  attention  to  the  fact  that,  owing 
to  the  weight  of  the  body,  the  limb  assumes  an 
abnormal  position,  which  eventually  becomes  per- 
manent, being  due,  not  to  contraction,  but  to 
abnormal  growth. 

The  "  spastic  paralysis  "  of  Erb  is  also  produc- 
tive of  club-foot.  This  condition  has  been  called 
by  Adams,  "paralysis  with  rigid  muscles,"  and  by 
Seguin,  "  tetanoid  paraplegia."  It  is  well  illustrated 
by  the  case  I  now  present. 

Case  I.  Tetanoid  paraplegia,  producing  double 
talipes  equino-varus. — Barney,  aged  six  years.  ]STo 
record  or  information  could  be  obtained  regarding 
previous  history.  Having  stripped  him,  it  will  be 
noticed  that  the  thighs  are  adducted  and  slightly 
flexed  upon  the  pelvis.  The  legs  are  held  firmly 
at  a  moderate  degree  of  flexion  at  the  knee-joint. 
The  feet  are  extended  and  inverted  in  the  position 
of  pronounced  equino-varus.  All  muscular  groups 
of  the  lower  limbs  are  in  a  condition  of  spasmodic 
rigidity.  You  will  notice  these  contractions  may 
be  temporarily  overcome  by  firm  and  continuous 
pressure,  but  immediately  reappear  upon  the  re- 
moval of  the  opposing  force.  Locomotion,  with 
assistance,  is  accomplished,  with  difficulty,  by  a 
swinging,  discordant  gait,  typical  of  the  disease, 
the  patient  walking  only  upon  the  ball  of  the  feet 


208  MEMOIR  OF  A.  S.  ROBERTS. 

and  toes,  the  weight  of  his  body  not  being  sufficient 
to  overcome  the  contraction  and  bring  the  heels  to 
the  floor.  The  other  symptoms  characteristic  of 
the  central  lesion — deficient  intelligence,  strabismus, 
exaggerated  muscular  reflexes,  and  general  rigidity 
and  spasm  of  the  muscular  system,  are  all  present. 
As  I  propose  to  operate  upon  this  patient,  I  will 
defer  a  further  consideration  of  his  feet  until  my 
next  clinic.  The  condition  appears  to  be  due,  in 
some  instances,  to  retarded  development  in  the 
motor  tract  of  the  brain ;  in  others,  to  a  lesion  in 
the  same  position,  followed  by  secondary  changes 
in  the  lateral  columns  of  the  cord.  The  researches 
of  Rupprecht,  of  Dresden,  not  only  show  that 
tenotomy  is  followed  in  some  of  these  cases  by 
improvement  in  the  position  of  the  feet,  but  that 
the  mental  state  is  also  appreciably  benefited  hy  the 
operation.  His  article  has  been  published  in  "Volk- 
mann's  series  of  clinical  lectures,  and  constitutes  an 
important  and  valuable  contribution  to  our  knowl- 
edge of  this  interesting  class  of  cases.  Various 
spinal  diseases,  acute  compression,  syphilis,  tumors, 
caries,  etc.,  are  frequently  productive  of  a  similar 
condition.  Other  diseases  of  the  nervous  system 
should  be  mentioned  as  causes  of  club-foot.  In 
rare  cases,  pseudo-hypertrophic  muscular  paralysis 
and  post-hcmiplegic  contractions  produce  the  de- 
formity, but  neuromimetic  conditions,  which  of  late 
years  have  attracted  much  attention,  are  more  fre- 
quently the  cause  of  it.  A  careful  elimination  of 
other  possible  etiological  factors  in  a  given  case, 
coupled  with  a  proper  appreciation  of  the  general 


CLUB-FOOT.  209 

condition,  will  usually  lead  to  correct  conclusions 
in  the  cases  of  the  latter  kind. 

Sayre  has  advocated  the  view  that  paralysis  due 
to  reflex  irritation  is,  in  many  instances,  productive 
of  talipes,  and  has  reported  cases  in  which  he  claims 
that  functional  disturbance  of  the  nervous  system 
can  cause  spasm  of  muscles,  which,  if  sufficiently 
prolonged,  while  healthy  growth  continues  in  their 
antagonists,  becomes  the  cause  of  a  permanent 
deformity.  Much  discussion  has  taken  place  con- 
cerning this  condition  as  a  cause  of  club-foot,  but 
I  do  not  consider  Dr.  Say  re's  theory  as  in  any  way 
tenable. 

Talipes  equinus  sometimes  occurs  as  a  concomi- 
tant of  the  paraplegia  of  Pott's  disease  of  the  spine, 
but  disappears  upon  recovery  from  the  paralysis ; 
joint  diseases  of  the  lower  extremity  are  also  potent 
factors  in  the  production  of  club-foot.  In  ankle- 
joint  disease  the  deformity  may  follow  osteitis  of 
the  articulation,  and  remain  as  a  permanent  condi- 
tion, due  to  anchylosis  of  the  joint  in  the  position 
of  extension.  In  hip-joint  disease,  it  would  be 
due  to  prolonged  malposition  during  the  period  of 
growth.  I  have  lately  seen  a  case  of  this  disease 
in  which  the  limb  upon  the  affected  side  was  short- 
ened but  one  inch,  and  in  which  there  was  a  marked 
equinus  accompanied  by  contraction  of  the  plantar 
fascia.  Occupations  requiring  long-continued  stand- 
ing in  one  position  can  be  also  considered  causative 
agents ;  printers,  bakers,  blacksmiths,  and  those 
engaged  in  kindred  trades  may  be  mentioned  as  the 
principal  sufferers.     The  enforced  position  and  the 

14 


210  MEMOIR  OF  A.  S.  ROBERTS. 

weight  of  the  body  are  the  factors  in  the  production 
of  this  variety  of  the  deformity,  which  is  most 
commonly  a  valgus.  The  same  remarks  will  apply 
to  the  valgus  of  adolescence,  due  probably  to  rapid 
growth  and  increased  weight  of  the  body,  without, 
however,  a  corresponding  development  of  the  mus- 
cles, aponeuroses,  and  ligaments  of  the  feet.  The 
influence  of  long-continued  decubitus  is  further 
shown  by  the  case  reported  by  Yolkmann,  in  which 
an  equinus  was  found,  after  prolonged  typhoid 
fever,  so  resistant  that  it  required  a  year's  treatment 
to  restore  the  feet  to  their  normal  position.  As  to 
traumatism,  it  will  be  only  necessary  to  allude  to 
the  possibility  of  wounds,  burns,  rupture  of  tendons, 
etc.  The  former  may  result  in  the  production  of 
deep  cicatrices,  which,  by  their  contraction,  tend  to 
draw  the  foot  into  a  deformed  position.  Spurious 
valgus,  or  splay-foot,  is  frequently  the  result  of 
rhachitis,  although,  as  before  mentioned,  occupa- 
tion is  often  an  important  factor  in  its  causation. 
All  these  forms  may  be  simulated  by  hysteria, 
and  this  class  of  cases  frequently  taxes  the  knowl- 
edge and  ingenuity  of  the  surgeon;  their  recog- 
nition lies  in  a  thorough  understanding  of  general 
morbid  conditions  and  a  careful  diagnosis  by  ex- 
clusion. 

Before  closing,  I  desire  to  call  your  attention  to 
the  morbid  anatomy  of  club-foot.  I  shall,  however, 
touch  upon  it  only  sufficiently  to  give  you  an  idea 
of  the  muscles  involved  in  the  production  of  the 
various  deformities,  and  will  illustrate  my  remarks 
by  reference  to  the  following  classification : 


CLUB-FOOT.  211 


Table  No.  V. 


Extension  (equinus) 


f  Gastrocnemius. 
J   Soleus. 
|   Plantaris. 
I  Peroneus  longus. 


Tibialis  anticus. 
Flexion  (calcaneus)      .         .     \   Peroneus  tertius. 


Extensor  longus  digitorum. 

Tibialis  anticus. 
Adduction  (varus)        .         .     -I   Tibialis  posticus. 


Flexor  longus  digitorum. 

Peroneus  longus. 
Abduction  (valgus)       .        .     -J   Peroneus  brevis. 

Peroneus  tertius. 

Dividing  the  muscles  into  three  groups,  which 
move  the  foot  in  four  directions,  as  shown  in  Table 
No.  V.,  we  have  a  posterior  group,  the  calf  muscles, 
the  gastrocnemius,  and  the  soleus,  and  two  anterior 
groups,  the  tibial  and  the  peroneal.  In  the  normal 
condition,  an  equilibrium  is  maintained  between 
these  muscles,  and  the  correct  anatomical  relation 
of  the  parts  is  preserved;  but  should  spasmodic 
contraction  or  paralysis  of  one  or  more  of  these 
groups  occur,  the  balance  is  destroyed,  and  deform- 
ity takes  places.  As  has  been  remarked,  the  purely 
primitive  forms  of  club-foot  are  extremely  rare, 
and  this  statement  will  apply  to  these  deformities, 
whether  they  be  congenital  or  acquired.  A  brief 
consideration  of  them,  however,  is  necessary  in 
order  that  a  clear  understanding  of  the  compound 
forms  which  are  encountered  most  frequently  in 
practice  may  be  obtained.  They  are  equinus,  cal- 
caneus, varus,  and  valgus;   the  two  former  being 


212  MEMOIR  OF  A.  S.  ROBERTS. 

anteroposterior  deformities ;  the  two  latter  occur- 
ring upon  a  transverse  plane. 

In  tali-pes  equinus  the  heel  is  raised,  the  patient 
walking  upon  the  ball  of  the  foot.  Here  we  find 
the  posterior  group  of  muscles,  consisting  of  the 
gastrocnemius  and  soleus,  contracted  and  shortened, 
the  tendo  Achillis  being  felt  as  a  tense  band.  In 
the  opposite  condition,  talipes  calcaneus,  the  anterior 
groups  of  muscles,  tibialis  anticus,  posticus,  and 
peronei,  are  at  fault,  and,  being  shortened,  maintain 
the  foot  in  the  position  of  flexion,  the  patient  walk- 
ing upon  the  heel.  Talipes  varus  manifests  itself 
by  inversion  and  adduction  of  the  foot,  the  deform- 
ity taking  place  anterior  to  Chopart's  joint ;  in  it 
the  sole  is  turned  inward  and  raised,  and  the  anterior 
portion  of  the  foot  adducted,  the  tibailis  anticus  and 
posticus  and  flexor  longus  digitorum  being  con- 
tracted. In  valgus,  on  the  contrary,  the  sole  is 
turned  outward,  and  its  outer  border  raised,  the 
peronei  being  the  muscles  at  fault.  In  this  de- 
formity, however,  the  plantar  fascia  is  involved, 
the  arch  of  the  foot  being  diminished  by  its  relaxa- 
tion. 

In  all  these  varieties,  changes  occur,  not  only  in 
the  muscles,  but  also  in  the  ligaments,  fascia?,  and 
in  the  bones  themselves,  Avhether  as  causes  or 
effects ;  but  we  shall  defer  the  study  of  them  until 
our  next  meeting,  my  object  in  briefly  mentioning 
the  primitive  deformities  now  being  merely  to  im- 
press upon  you  the  character  of  the  changed  relation 
of  the  parts  from  an  anatomical  rather  than  a  patho- 
logical stand-point,  which  latter  condition  can  be 


CLUB-FOOT.  213 

best  considered  when  we  come  to  speak  of  the  most 
frequent  of  all  the  forms  of  club-foot,  namely, 
talipes  equino-varus. 


LECTURE  II. 

Gentlemen  :  Our  last  meeting  closed  with  a 
brief  description  of  the  primitive  forms  of  club-foot. 
We  now  pass  to  the  consideration  of  the  treatment 
of  talipes  in  general,  such  modifications  as  may  be 
necessary  to  correct  the  deformity  in  any  special 
case  which  may  come  before  us  being  deferred  until 
we  discuss  the  compound  forms.  Properly  to  cope 
with  these  conditions,  it  is  essential  that  you  should 
thoroughly  comprehend  the  factors,  pathological 
and  mechanical,  which  produce  them.  Because  of 
the  lack  of  exact  knowledge  upon  the  subject  by 
the  profession,  many  cases  of  deformity  remain 
uncured,  and  scores  of  children  who  could  other- 
wise be  relieved  are  left  to  the  care  of  inconsiderate 
instrument  makers.  It  is  only  by  the  intelligent 
application  of  measures  fitted  exactly  to  the  case 
that  success  can  be  achieved ;  and  the  knowledge 
requisite  to  do  this  is  not  possessed  by  the  mechani- 
cian in  any  greater  degree  than  is  the  knowledge 
necessary  properly  to  care  for  a  medical  case  a  part 
of  the  education  of  the  apothecary.  Nor  has  the 
training  of  the  general  practitioner  been  such  as  to 
make  him  an  adept  in  this  branch  of  surgery,  and 
when  it  is  considered  how  few  are  his  opportunities 


214  MEMOIR  OF  A.  S.  ROBERTS. 

of  seeing  many  such  cases,  it  is  not  strange  that 
extreme  deformities  are  frequent,  and  that  their 
existence  and  progression  should  be  an  opprobrium. 
It  is  only  by  the  dissemination  of  knowledge  by 
clinical  teaching,  and  the  establishment  of  institu- 
tions dedicated  to  the  care  of  these  special  cases, 
that  a  better  state  of  things  may  be  hoped  for,  and 
the  importance  of  such  measures  cannot  be  over- 
estimated. 

The  object  of  treatment  in  club-foot  is  not  only 
to  remove  the  existing  deformity,  but  to  restore  to 
the  foot  its  functions  ;  and  to  do  this  many  proced- 
ures have  been  resorted  to  which  have  been  in  turn 
discarded.  We  may  consider  the  methods  now  in 
use  as  mechanical  and  operative.  First  among  the 
former  is  manipulation,  applied  so  as  to  stretch 
the  contracted  tissues,  passive  motion,  massage, 
shampooing,  and  electricity  being  used  the  while, 
to  aid  in  the  restoration  of  function.  The  hand,  if 
pressure  and  traction  to  the  contracted  tissues  could 
be  continuously  applied  by  it,  would,  no  doubt,  con- 
stitute the  best  instrument  for  the  relief  of  club-foot ; 
the  apparatus  which  is  best  adapted  to  take  its  place 
is  that  which  should  be  relied  upon  in  the  mechani- 
cal treatment  of  the  deformity. 

Massage  and  electricity  serve,  in  paralytic  cases, 
to  restore,  as  far  as  possible,  the  functional  activity 
of  the  paretic  muscles,  and  should  always  be  em- 
ployed as  adjuvants  in  such  cases. 

Tenotomy,  for  the  division  of  contracted  tendons, 
called  .iponcurotomy  when  performed  upon  fasciae 
and  aponeuroses,  was  resorted  to  first  by  Delpech, 


CLUB-FOOT.  215 

of  Montpellier,  France.  It  was  not,  however,  gen- 
erally employed  nntil  Stromeyer,  of  Hanover,  ren- 
dered it  popular.  Little  introduced  the  operation 
into  England,  and  Dickson,  of  South  Carolina,  first 
performed  it  in  America.  To  Deltmold,  of  New 
York,  and  Mutter,  of  this  city,  however,  is  due 
much  of  the  credit  of  making  the  operation  popular 
in  this  country.  Opinions  differ  as  to  the  indica- 
tions for  tenotomy  and  the  proper  time  for  its 
performance ;  whether,  for  instance,  in  cases  of  con- 
genital talipes,  it  should  be  done  prior  to  the  time 
at  which  the  child  is  able  to  walk,  or  subsequently. 
'No  difference  of  opinion  can  exist  as  to  the  advisa- 
bility of  early  operation  in  cases  in  which  the  nature 
or  extent  of  the  deformity  renders  correction  by 
mechanical  means  alone  impossible ;  but  as  experi- 
ence is  the  only  guide  to  discrimination,  mechanical 
appliances  should  always  be  granted  a  fair  trial 
before  resorting  to  operation.  Rigidity,  or  the 
reflex  spasm  caused  by  point  pressure  mentioned 
by  Sayre,  is  not  in  itself  a  safe  criterion,  nor  does 
excessive  deformity,  taken  alone,  furnish  a  reliable 
indication. 

Retentive  dressings,  such  as  splints  of  silicate  of 
coda  or  plaster  of  Paris,  are  used,  either  alone  or 
after  tenotomy,  serving  to  retain  the  foot  in  the 
position  acquired  after  manipulation  or  operation. 
The  rubber  muscle  advocated  by  Richard  Barwell, 
of  London,  and  extensively  used  by  Sayre,  may  be 
employed  to  take  the  place  of  paralyzed  muscles ; 
or  Scarpa's  shoe,  as  variously  modified,  may  be 
applied  to  fix  the  foot  and  exert  traction. 


216  MEMOIR  OF  A.  S.  ROBERTS. 

As  I  mentioned  to  you  at  our  last  meeting,  the 
type  of  club-foot  with  which  you  will  most  fre- 
quently meet  is  talipes  equino-varus.  The  princi- 
ples of  treatment  appropriate  to  the  mechanical 
conditions  present  can  be  applied  to  any  of  the  other 
forms.  This  deformity  is  well  illustrated  by  the 
case  I  now  show  you. 

Case  II.  Congenital  double  talijjes  eauino-varus  ; 
mechanical  extension  y  recovery. — Richard  C,  aged 
four  months,  referred  to  my  care  from  the  Obstet- 
rical Department  of  this  hospital.  The  deformity, 
which  in  this  case  affects  both  feet,  takes  place  upon 
an  anteroposterior  and  a  transverse  plane,  combin- 
ing elevation  of  the  heel,  equinus,  and  inversion  of 
the  foot,  with  elevation  of  the  internal  border  of  the 
sole,  varus.  The  os  calcis  is  drawn  upward  by  the 
contraction  of  the  gastrocnemius  and  soleus,  and 
rotated  in  such  a  manner  that  its  posterior  border 
is  turned  outward  and  its  anterior  border  inward. 
The  bones  of  the  tarsus,  following  the  direction  of 
the  os  calcis,  are  inverted,  and  the  inner  sole  raised 
by  the  action  of  the  tibialis  anticus.  The  altered 
relation  of  the  bones  of  the  tarsus  leads  to  change 
in  form,  especially  of  the  articular  facets  ;  and  some 
have  considered  these  alterations  as  causative.  This 
is  by  far  the  most  frequent  of  the  congenital  forms 
of  club-foot,  and  it  has  been  argued  that  arrest  of 
development  in  bones  and  muscles  is  the  principal 
etiological  factor.  As  the  various  theories  on  the 
subject  were  discussed  in  our  former  clinic,  they 
need  not  detain  us  here. 

The  lateral  deflection  of  the  anterior  portion  of 


CLUB-FOOT. 


217 


the  foot,  as  compared  to  that  of  the  normal  imprint, 
is  well  shown  in  the  following  cuts.  The  outline 
tracings  are  from  impressions  of  the  feet  of  patients 
suffering  from  various  deformities,  obtained  after 
the  method  advocated  by  Rohmer  ("Les  Variations 
de  Forme  Normales  et  Pathologiques  de  la  Plante 
du  Pied,"  These,  Nancy,  1879),  consisting  of  first 

Fig.  50. 


covering  the  plantar  surface  of  the  foot  with  lamp- 
black, which  leaves  a  correct  impression  of  the  sole 
upon  white  paper,  on  which  the  patients  are  then 
requested  to  walk.  To  obtain  a  correct  basis  of 
measurement,  and  still  further  to  carry  out  Rohmer's 
researches  as  a  guide  to  treatment,  I  selected  the 
medio-tarsal  joint  as  a  base  line  of  measurement ; 
erecting  upon  it  a  perpendicular  corresponding  to 
the  long  axis  of  the  os  calcis.  As  they  are  com- 
paratively stable  structures  in  all  deflections  from 
the  normal  condition  of  the  foot,  the  position  and 


218 


MEMOIR  OF  A.  S.  ROBERTS. 


character  of  deformity  could  be  readily  determined 
by  a  comparison  of  the  degrees  of  variation. 

In  the  thirty-two  normal  feet  measured,  I  have 
found  the  angle  of  deflection,  which  is  represented 
by  an  imaginary  line  passing  through  the  head  of 
the  metatarsal  bone  of  the  great  toe,  to  range  be- 
tween 26  and  37  degrees  (average,  20  males,  34.8 
degrees ;  12  females,  31.5  degrees) ;  typical  exam- 
ples may  be  seen  in  Figs.  49  and  50,  males,  and 
Figs.  51  and  52,  females. 


Fig.  51. 


Fig.  52. 


In  valgus,  on  the  contrary,  the  angle  of  internal 
deflection  is  reduced  to  from  12  degrees  in  moderate 
cases,  to  5  degrees  in  extreme  ones,  illustrated  by 
Figs.  53  and  54,  which  represent  the  imprint  of 
patient's  feet  suffering  from  acquired  "flat-foot," 
of  rhachitic  origin.  From  an  examination  of  seven 
cases  I  have  ascertained  the  average  deviation  from 
the  perpendicular  to  be  about  8.2  degrees. 

The  adduction  of  varus   has  in  two   instances 


CLUB-FOOT. 


219 


reached  an  internal  rotation  of  63  degrees.  I  con- 
sider all  feet  that  have  an  internal  deviation  in 
excess  of  40  degrees  as  abnormal.  An  examina- 
tion of  fourteen  cases  of  varus  yields  an  average  of 


51  degrees. 


Fig.  53. 


Fig.  54. 


This  method  of  measurement  I  believe  to  be  of 
importance,  as  furnishing  us  with  an  excellent  and 
accurate  guide  to  the  amount  of  deformity,  as  well 
as  affording  an  opportunity  of  determining  the 
improvement  that  may  follow  any  plan  of  treatment 
instituted. 

In  the  correction  of  equino-varus,  as  in  that  of 
the  other  compound  forms,  it  is  best  to  divide  the 
process  of  rectification  into  two  stages,  the  object 
being  to  overcome  one  of  the  factors  of  the  deform- 
ity before  attacking  the  other.  The  reason  for  this 
will  be  sufficiently  obvious  when  it  is  considered 
that  the  altered  relations  of  the  tissues  of  the  foot 


220 


MEMOIR  OF  A.  S.  ROBERTS. 


take  place  upon  two  planes  at  right  angles  to  each 
other.  Our  endeavor,  then,  should  be  directed  first 
to  the  lateral  or  varus  element  of  the  deformity. 
Manipulation  should  be  systematically  used,  and, 
while  sufficient  in  very  mild  cases,  is  of  great  ser- 
vice as  an  adjuvant  in  severe  ones.  It  should  be 
applied  several  times  daily,  and  in  the  following 
manner :  The  heel  is  firmly  grasped  by  one  hand, 
while  with  the  other  the  anterior  portion  of  the  foot 
is  gradually  and  steadily  brought  into  a  position  of 
valgus,  and  held  there  for  a  few  moments,  then 
allowed  to  return  to  its  abnormal  position.     After 

Fig.  55. 


the  manipulation  has  been  repeated  several  times  at 
short  intervals  the  foot  may  be  placed  in  any  light 
dressing.  This  splint  will  retain  the  foot  in  its  cor- 
rected position,  and  may  be  modified  from  time  to 
time  to  suit  the  lessened  amount  of  varus.  It  may 
consist  of  material  suited  to  the  case.  In  the  milder 
degrees  of  the  deformity,  adhesive  plaster  wound 
around  the  foot  and  attached  to  the  fibular  aspect 
of  the  leg  answers  the  purpose,  but  when  greater 
Btrength  is  required  splints  made  of  leather,  gutta 


CLUB-FOOT. 


221 


percha,  or  hatters'  felt  may  be  moulded  to  the  parts, 
and  secured  by  a  roller  bandage.  These  have  the 
advantage  over  fixed  dressings  of  plaster  of  Paris 
in  allowing  inspection  as  frequently  as  may  be 
desired,  together  with  the  application  of  massage, 
electricity,  etc. 

Fig.  57. 


But  the  majority  of  cases  of  varus  cannot  be 
cured  by  such  simple  means.  As  in  this  case, 
which  is  typical  of  congenital  equino-varus,  we 
have  absolute  deformity  to  overcome ;  tendons  and 
muscles  are  shortened,  and  the  tissues  structurally 


222 


MEMOIR  OF  A.  S.  ROBERTS. 


altered.  The  so-called  "  mild  measures  "  will  not 
avail,  and  time  occupied  in  their  trial  is  wasted. 
Nothing  will  be  of  benefit  except  the  application  of 
instruments  which  by  their  accuracy  of  construc- 
tion and  power  will  appropriately  stretch  the  tissues 
involved,  or,  after  a  fair  trial  of  these,  operations 
which  will  divide  the  resisting  structures. 


In  such  cases  the  shoe  which  I  now  show  you 
(Fig.  57)  is  of  the  greatest  service.  It  is  a  modifi- 
cation of  Taylor's  ankle  support,  and  in  its  original 
form  was  devised  by  Shaffer,  of  New  York.  To 
this  brace  I  have  given  more  power  by  substituting 
in  the  sole  plate,  for  his  extension  bar  a  triple  thread 
screw  worked  by  a  key  at  b,  and  by  throwing  the 


CLUB-FOOT. 


223 


centre  of  motion  further  to  the  outer  side  of  the  sole 
at  A  (Fig.  58).  The  instrument  consists  of  a  steel 
trough  fitted  to  the  inner  side  of  the  leg,  extending 
from  the  upper  part  of  the  tibia  to  the  internal 
malleolus.  A  hinge  at  o  (Fig.  57),  the  direction  of 
which  is  such  as  to  allow  pressure  exerted  upon  it 
at  right  angles  to  operate  upon  the  anterior  or 
lateral  deformity,  connects  this  trough  with  a  con- 


tinuation, or  foot  portion,  which  is  joined  by  a  plate 
to  receive  the  foot  by  an  antero-posterior  joint,  so 
that  the  shoe  may  be  accurately  adjusted  to  the 
"  equinus  "  element  of  the  deformity.     The  endless 


224 


MEMOIR  OF  A.  S.  ROBERTS. 


screw  which  I  show  you  at  A  (Fig.  57)  is  operated 
by  a  key,  and  acts  through  this  hinge  upon  the 
anterior  portion  of  the  foot.  The  sole  is  divided 
opposite  the  medio-tarsal  joint,  and  by  means  of  the 
screw  b  (Figs.  58,  59)  acting  upon  the  centre  of 
motion  at  a  allows  of  extreme  and  powerful  abduc- 
tion of  the  anterior  part  of  the  foot.    The  apparatus 

Fig.  60. 


having  been  applied  to  fit  the  deformity,  and  se- 
cured by  a  bandage  (f,  f),  the  foot  is  thrown  into 
a  position  of  valgus  by  means  of  the  screw  A  (Fig. 
57)  acting  upon  the  hinge  c,  and  this  is  supple- 
mented by  applying  the  force  of  the  screw  in  the  sole 
plate  b  (Fig.  58),  which  still  further  acts  upon  the 
anterior  deformity.  It  is  better  to  use  the  apparatus 
by  stretching  the  tissues  several  times  in  succession, 


CLUB-FOOT.  225 

and,  after  allowing  them  to  relax,  to  adjust  the  brace 
to  the  corrected  position.  Having  by  this  method 
overcome  the  lateral  deformity,  as  illustrated  in 
Fig.  60,  our  attention  must  be  directed  to  the 
anteroposterior  or  equinus  element. 

To  correct  this  deformity  by  mechanical  means 
it  is  necessary  to  apply  an  instrument  which, 
through  the  tendo  Achillis,  will  elongate  the  con- 
tracted posterior  muscles  of  the  calf.  To  accom- 
plish this  many  modifications  of  Scarpa's  shoe  have 
been  devised.  They  consist  of  two  steel  uprights 
extending  from  the  upper  part  of  the  tibia  to  the 
ankle-joint,  and  are  attached  to  a  heel-cup  and  sole, 
to  hold  the  foot,  the  heel  being  strapped  in  its  place 
by  means  of  a  band  of  webbing,  a  bandage,  or  sim- 
ilar material  passing  over  the  instep.  The  sole  may, 
or  may  not,  be  divided  opposite  the  medio-tarsal 
junction.  At  first  sight,  such  an  apparatus  would 
seem  to  fulfil  the  indication  of  applying  a  force 
sufficient  to  flex  the  foot  and  stretch  the  tendo 
Achillis,  but  in  practice  we  find  that  as  the  neces- 
sary power  is  exerted,  the  centre  of  motion  in  the 
instrument  being  opposite  the  ankle-joint,  the  heel- 
cup  slips  away  from  the  os  calcis,  and  the  posterior 
border  of  the  foot  is  found  resting  upon  the  top  of 
the  heel-cup.  To  obviate  this,  Shaffer  has  in  his 
extension  shoe,  which  I  now  proceed  to  apply  to 
this  patient  (Fig.  61),  divided  the  sole  of  the  brace 
opposite  Chopart's  joint,  and  attached  to  the  ante- 
rior portion  or  sole  an  extension  bar  which  is  worked 
by  a  key  which  is  introduced  beneath  the  heel-cup 
at  b.     The  shoe  having  been  applied  extended  to  an 

15 


226 


MEMOIR  OF  A.  S.  ROBERTS. 


angle  corresjjonding  to  the  angle  of  deformity,  and 
the  heel  secured  in  its  place  by  a  strap  passing  over 
the  instep,  e,  the  os  calcis  is  further  secured  by  a 
strap,  d,  passing  around  it  posteriorly  and  attached 
to  the  buckles  upon  either  side  of  the  anterior  por- 
tion of  the  sole  plate.    When  flexion  is  made  by  the 

Fig.  61. 


key  at  a,  which  acts  upon  the  endless  screw  oppo- 
site the  ankle-joint,  c,  the  tendency  of  the  heel,  as 
you  see  in  Fig.  62,  is  to  slip  away  and  rest  upon 
the  upper  border  of  the  heel-cup,  and  the  degree  of 
flexion  of  the  foot  does  not  correspond  to  that  of  the 
brace.  If  now  we  insert  the  key  below  the  heel- 
cup  at  b,  and  throw  the  anterior  portion  of  the  sole 


CLUB-FOOT. 


227 


forward,  the  os  calcis  is  dragged  upon  by  the  strap 
passing  over  it  at  d,  and  the  centre  of  motion  is 
transferred  from  a  point  opposite  the  ankle-joint,  to 
a  point  represented  by  the  centre  of  the  strap,  e^ 
which  passes  over  the  instep,  and  the  heel  descends 
until  it  rests  upon  the  extension  bar.     The  tendo 

Fig.  62. 


Achillis  is  thus  thoroughly  put  upon  the  stretch,, 
and  may  be  felt  as  a  tense  band  (see  Fig.  63).  The 
operation  is  repeated  several  times  at  each  sitting,. 
and  the  amount  of  flexion  thus  gained  is  held  by 
readjustment  of  the  brace  in  the  acquired  position. 
No  danger  need  be  apprehended  from  interference 


228 


MEMOIR  OF  A.  S.  ROBERTS. 


with  the  circulation,  if  proper  precautions  be  ob- 
served ;  the  pressure  is  not  continuous,  being  rather 
a  momentary  overstretching,  followed  by  relaxation. 
The  foot  should  be  inspected  daily.  After  the  treat- 
ment has  resulted  in  bringing  the  foot  to  a  right 
angle  with  the  leg,  a  retention-shoe  with  stop-joint 

Fig.  63. 


should  be  worn,  to  keep  the  foot  in  the  corrected 
position,  and  a  similar  apparatus  must  be  applied 
during  the  night  throughout  the  treatment.  Here 
let  me  remark  that  a  cure  is  not  effected  when  the 
amount  of  possible  flexion  of  the  foot  forms  a  right 
anerle  with  the  tibia. 


CLUB-FOOT. 


229 


Referring  to  the  diagram  (Fig.  64),  you  will 
observe  that  the  normal  foot  in  extreme  flexion 
forms  with  the  leg  an  angle  of  about  70  degrees, 
and  at  the  ankle-joint  motion  is  possible,  in  the 
normal  condition,  through  an  arc  of  which  the 
extremes  are  represented  by  135  degrees  of  exten- 


Fig.  64. 


r**^^ 


sion  and  70  degrees  of  flexion.  Our  endeavor  in 
the  treatment  of  talipes  equinus  should  be  to  make 
the  acquired  flexion  reach  this  amount  as  nearly  as 
possible.  In  connection  with  this  subject,  I  wish 
to  call  attention  to  the  existence  of  cases  of  incom- 
plete equinus,  designated  "non-deforming  club-foot." 


230  MEMOIR  OF  A.  S.  ROBERTS. 

In  this  condition  flexion  is  impossible  beyond  90 
degrees,  and  the  deformity  is  amenable  to  the  treat- 
ment just  described. 

Case  III.  Acquired  double  talipes  equino-varus 
from  tetanoid  paraplegia ;  tenotomy  of  each  tendo 
Aclnllis. — You  will  recollect  the  case  presented  at 
our  last  meeting,  which  comes  before  us  now  for 
operation.  In  performing  tenotomy,  much  of  its 
success  is  due  to  attention  to  detail.  Two  teno- 
tomes are  necessary ;  one  sharp-pointed,  with  which 
to  puncture  the  skin,  and  the  other  probe-pointed, 
which  is  introduced  through  the  puncture  and  be- 
neath the  tendon  or  fascia  to  be  divided.  The  parts 
having  been  rendered  aseptic  by  cleansing  with  a 
solution  of  1  :  2000  of  bichloride  of  mercury,  and 
put  upon  the  stretch  by  flexing  the  foot,  the  punc- 
ture in  the  integument  is  made  over  the  central 
portion  of  the  tendon  in  such  a  manner  that  the 
incision  in  the  skin  and  that  of  the  deeper  tissues 
shall  not  correspond  after  relaxation  of  the  parts. 
Through  this  puncture  the  probe-pointed  tenotome 
is  introduced  flatwise  beneath  the  tendon  and  as 
close  to  its  deep  surface  as  possible.  The  cutting 
edge  being  now  turned  toward  it,  the  tendon  is 
divided  by  a  sawing  motion  of  the  knife.  An 
assistant  keeps  the  tissues  upon  the  stretch  until 
the  operation  is  almost  completed,  but  relaxes  his 
hold  before  the  tendon  is  thoroughly  divided,  to 
preclude  the  possibility  of  the  instrument  cutting 
its  way  through  the  skin.  The  tenotome  is  again 
turned  upon  its  side,  and  withdrawn  through  the 
puncture,  the  operator  placing  his   finger  over  its 


CLUB-FOOT.  231 

point  of  exit,  dusting  with  iodoform,  and  sealing 
with  a  pledget  of  cotton  saturated  with  compound 
tincture  of  benzoin,  which  forms  a  pellicle  and  pre- 
vents the  entrance  of  air.  After  the  operation  the 
foot  is  placed  in  the  extension  brace,  in  order  that 
its  degree  of  flexion  may  be  controlled.  This  pos- 
sesses the  great  advantage  over  fixed  plaster-of- 
Paris  dressings  of  allowing  frequent  inspection  of 
the  parts. 

I  shall  only  mention  the  operations  of  myotomy, 
or  division  of  muscles;  tarsotomy,  or  osteotomy  of 
the  tarsal  bones ;  tarsectomy,  or  the  removal  of  a 
wedge-shaped  piece  of  bone ;  open  incision,  as  advo- 
cated by  Phelps  and  Hingston,  instead  of  subcu- 
taneous tenotomy ;  and  amputation  as  a  last  resort. 
These  are  so  rarely  performed  and  so  little  neces- 
sary, that  it  is  only  essential  that  you  should  know 
that  such  procedures  have  been  devised. 

The  next  case  I  have  to  show  you  is  one  of 
acquired  talipes  calcaneus. 

Case  IV.  Acquired  single  talipes  calcaneus  from 
infantile  spinal  paralysis  ;  application  of  BarweWs 
rubber  muscle  ;  improvement. — Maggie  B.,  aged  ten, 
first  presented  for  treatment  in  the  Orthopedic  Dis- 
pensary of  the  University  of  Pennsylvania.  She 
has  kindly  consented  to  appear  before  you  to-day. 
You  will  notice  the  characteristic  deformity,  the 
foot  being  flexed  by  the  action  of  the  anterior 
groups  of  muscles,  the  patient  walking  upon  the 
heel.  In  this  condition,  no  treatment  does  so  well 
as  the  application  of  elastic  force,  advocated  by 
Bar  well.      The  rubber  supplies  the   place  of  the 


232  MEMOIR  OF  A.  S.  ROBERTS. 

paralyzed  gastrocnemius  and  soleus,  and  should  be 
applied  as  you  see  in  this  case.  To  the  shoe  are 
attached  two  uprights  with  an  anteroposterior  joint 
opposite  the  ankle.  It  is  important  that  this  joint 
should  be  so  arranged  that,  while  it  will  permit 
flexion  to  any  degree,  it  will  stop  extension  at  a 
right  angle.  The  posterior  rubber  muscle  is  at- 
tached above  to  a  band  which  passes  around  the 
upper  part  of  the  calf  and  below  to  the  heel  of  the 
shoe.  Should  there  be  much  contraction  of  the 
anterior  muscles,  their  tendons  may  be  divided  in 
the  manner  described,  before  the  application  of  the 
apparatus.  An  operation  has  been  devised  for 
exsection  of  a  portion  of  the  tendo  Achillis  for  the 
radical  cure  of  this  condition,  and  consists  in  the 
removal  of  a  portion  of  the  tendon  and  the  stitching 
together  of  the  divided  ends. 

The  next  case  I  have  to  exhibit  illustrates  a  very 
important  principle  in  treatment. 

Case  V.  Acquired  single  talipes  equino-varus ; 
mechanical  extension,  ajwneurotomy ;  recovery. — 
Joseph  F.,  aged  ten  years,  applied  to  the  Ortho- 
pedic Dispensary  of  the  University  Hospital  for 
relief  from  a  congenital  talipes  equino-varus  with 
pronounced  cavus.  The  case  was  treated  by  me- 
chanical extension,  as  described  when  speaking  of 
talipes  equino-varus,  and  resulted  in  the  perfect 
reduction  of  the  equinus  and  varus.  There  remained, 
however,  marked  cavus  caused  by  contraction  of 
the  plantar  fascia.  The  extension-shoe  was  applied 
with  the  hope  of  relieving  this  condition,  but  with- 
out result,  when  aponeurotomy   was   resorted  to. 


CLUB-FOOT.  233 

Several  operations  were  performed,  the  knife  being 
entered  beneath  the  plantar  fascia,  and  the  resisting 
tissues  nicked,  and  the  extent  of  the  division  was 
regulated  by  the  degree  of  relaxation  of  the  plantar 
arch  resulting  from  each  operation.  As  you  see, 
the  boy  has  made  a  perfect  recovery. 

I  wish  to  draw  your  attention  especially  to  the 
inefficacy  of  mechanical  means  in  cases  of  cavus 
with  marked  contraction  of  the  plantar  fascia,  and 
the  reason  will  be  readily  understood  if  we  consider 
the  structure  and  function  of  the  arch  of  the  foot. 
In  those  forms  of  talipes  which  depend  upon  contrac- 
tion of  muscles,  mechanical  force  applied  through 
the  tendon  will  act  upon  muscular  tissue  and  elon- 
gate it.  The  plantar  arch,  on  the  contrary,  is  con- 
structed with  the  view  of  supporting  the  weight  of 
the  body,  the  tissues  entering  into  its  formation  are 
of  the  most  unyielding  character,  i.  e.,  plantar 
fascia,  and  no  amount  of  mechanical  power  which 
can  be  safely  applied  will  suffice  in  cases  in  which 
it  is  markedly  contracted.  Aponeurotomy  is  neces- 
sary, and  performed  tentatively,  nicking  a  little, 
and  repeated  as  often  as  necessary,  yields  the  best 
results. 

The  last  patient  to  which  I  shall  call  your  atten- 
tion to-day  illustrates  a  condition  the  opposite  of 
cavus,  the  essential  element  being  relaxation  of  the 
plantar  tissues. 

Case  VI.  Acquired  double  talipes  planus  ("flat- 
foot"}  from  rhachitis;  plantar  springs;  improve- 
ment.— John  B.,  aged  thirteen  years.  This  case 
shows  the  deformity  in  a  marked  degree,  the  plantar 


234  MEMOIR  OF  A.  S.  ROBERTS. 

arch  being  relaxed  and  flattened,  the  internal  border 
of  the  foot  resting  upon  the  ground.  These  cases, 
in  which  there  is  much  pain,  have  received  the 
appellation  of  "inflammatory  valgus."  Besides 
rhachitis,  the  other  causes  of  this  deformity  are 
paralysis,  ankle-joint  disease,  and  rheumatism.  It 
also  occurs  in  growing  children,  and  in  those  whose 
occupation  necessitates  long  standing  in  one  posi- 
tion. In  mild  cases  the  most  efficient  means  at 
our  disposal  for  its  relief  are  the  plantar  springs, 
which  have  been  applied  in  this  case,  with  the 
resulting  improvement  which  you  notice.  They 
are  made  as  follows  : 

A  tempered  steel  spring  is  placed  inside  the 
shank  of  the  shoe,  moulded  in  such  a  manner  as  to 
support  the  relaxed  tissues  of  the  arch  and  over- 
come the  tendency  of  the  foot  to  e version.  In  cases 
of  greater  severity  it  should  be  supplemented  by 
an  ankle  support  having  a  pad  which  will  make 
pressure  upon  the  internal  malleolus. 

All  forms  of  club-foot  may  be  simulated  by  the 
neuromimetic  or  hysterical  conditions.  In  cases  of 
this  kind  the  pedal  deformity  may  be  accompanied 
by  contractions  in  other  regions,  or  it  may  be  the 
only  symptom  outside  the  general  condition,  and 
the  dependence  of  the  local  trouble  upon  the  neu- 
rotic state  may  be  very  difficult  to  discover.  Here, 
as  in  neuromimetic  affections  in  other  regions,  con- 
tractions and  contractures  may  so  counterfeit  their 
organic  prototypes  as  to  render  positive  differentia- 
tion well-nigh  impossible.  In  making  a  diagnosis, 
the  general  condition  and  surroundings  of  the  pa- 


CLUB-FOOT.  235 

tient,  the  hereditary  history,  together  with  any  fact 
as  to  previous  mimicry  or  simulative  tendency, 
should  be  carefully  weighed.  The  local  condition 
alone  is  not  a  reliable  guide :  the  contractions  are 
often  as  unyielding  as  in  the  real  deformity ;  the 
muscles  do  not  relax  during  sleep,  and  the  condition 
may  be  very  persistent.  It  is  only  by  a  careful 
consideration  of  each  case,  and  a  diagnosis  by  exclu- 
sion, that  a  correct  opinion  can  be  formed. 

The  care  of  this  condition  taxes  the  patience  and 
ingenuity  of  the  surgeon  to  the  utmost.  In  few 
words,  the  treatment  is  that  of  the  general  neurotic 
state,  coupled  with  the  absolute  avoidance  of  all 
local  manipulations  and  mechanical  contrivances 
suited  to  similar  organic  deformities,  and  which 
would  here  direct  the  attention  of  the  patient  to  the 
affected  member.  Despite  the  most  careful  general 
treatment,  the  deformity  may  persist  for  months,  as 
shown  by  Dr.  S.  Weir  Mitchell,1  of  this  city.  In  this 
case,  hysterical  single  talipes  equinus  in  a  young 
lady  of  fifteen  had  continued  for  two  years,  notwith- 
standing the  fact  that  treatment  had  removed  all 
the  more  general  symptoms  of  the  hysterical  state; 
and  it  was  not  until  division  of  the  tendo  Achillis, 
which  I  performed  after  consultation  with  Dr.  Mit- 
chell, that  the  deformity  finally  disappeared. 

1  Lectures  on  Diseases  of  the  Nervous  System,  especially  in 
Women.  By  S.  Weir  Mitchell,  M.D.,  p.  129.  Philadelphia:  Lea 
Bros.  &  Co.,  1885. 


KNOCK-KNEE   AND    BOW-LEGS, 


WITH  REMARKS  ON 


EHACHITIS 


KNOCK-KNEE  AND  BOW-LEGS, 


WITH  REMARKS  ON 


RHACHITIS. 


LECTURE  I. 


Gentlemen:  As  Macewen,  of  Glasgow,  and 
others  have,  by  the  revival  of  the  operation  of  oste- 
otomy for  the  cure  of  knock-knee  and  bow-legs, 
renewed  the  interest  in  these  deformities,  and  placed 
themselves  on  record  as  being  ardent  advocates  of 
operative  procedures  for  their  radical  relief,  it  will 
be  my  endeavor  to  call  your  attention  especially  to 
these  important  malformations ;  and  I  purpose  to 
inquire  how  far  operations  are  a  necessity  for  their 
correction,  and  what  proportion  and  class  of  cases 
can  be  best  treated  by  such  means,  and,  also? 
whether  mechanical  methods  of  treatment  are  not 
fully  as  important  as  those  of  a  more  radical  nature. 

Mechanically  considered,  knock-knee  and  bow- 
legs result  from  an  alteration  in  the  plane  of  the 
articulating  surfaces  of  the  bones  entering  into  the 
formation  of  the  knee-joint,  with  or  without  a  curv- 

1  Clinical  Lectures  on  Orthopedic  Surgery,  delivered  at  the  Phila- 
delphia Hospital. 


240  MEMOIR  OF  A.  S.  ROBERTS. 

ing  of  the  shaft  of  the  femur  or  tibia,  whereby  the 
knee  is  thrown  either  inside  or  outside  a  perpendic- 
ular line  let  fall  from  the  head  of  the  femur  to  a 
point  midway  betAveen  the  two  malleoli.  Should 
the  knee  fall  inside  this  line,  the  resulting  deformity 
is  known  as  knock-knee  or  genu  valgum,  the  oppo- 
site condition,  that  in  which  the  knee  is  without  the 
perpendicular,  being  called  bow-legs  or  genu  varum, 
and  the  causes  producing  these  results  may  be 
summarized  as :  1.  Rhachitis.  2.  Ligamentous 
relaxation.  3.  Central  disturbances  destroying  the 
equilibrium  of  muscular  action,  or  aifecting  the 
nutrition  of  the  epiphyses. 

By  far  the  most  frequent  and  important  cause  is 
the  one  first  mentioned,  namely  rhachitis,  which 
favors  the  production  of  deformity  by  the  softening 
of  bone  and  the  relaxation  of  ligaments  which 
occurs  during  its  progress,  whereby  we  have  an 
alteration  of  the  normal  development  of  the  cartilage 
and  periosteum  from  increased  cell  proliferation,  the 
resulting  cartilaginous  and  osseous  tissues  being 
less  completely  matured,  and  much  more  retarded 
in  their  development  than  in  the  normal  course  of 
bone  growth.  Moreover,  the  rapidly  proliferated 
cells  are  not  supplied  with  a  sufficient  quantity  of 
inorganic  elements,  and,  therefore,  a  relative  excess 
of  organic  material  with  a  corresponding  deficiency 
of  lime  salts  occurs.  In  other  words,  the  cells 
which  are  deposited  are  immature,  half  ripe  in  char- 
acter, and  the  dyscrasia  interferes  with  their  normal 
progression  toward  maturity.  When  the  disease 
finds  expression  in  the  epiphyses,  it  occurs  at  the 


KNOCK-KNEE  AND  BOW-LEGS.  241 

epiphyseal  juncture,  at  which  point  we  find  the 
cartilage  filled  with  young  cells  which  are  neither 
mature  cartilage  cells  nor  true  bone  cells,  but  have 
a  character  which  partakes  of  both.  In  consequence 
of  this  abnormal  cell  deposit  we  find  the  thickness 
of  the  cartilage  is  increased,  and  the  structure  has 
not  the  resisting  quality  so  marked  in  health ;  on 
the  contrary,  the  aggregation  of  cells  forms  a  soft, 
non-resisting  material  which  breaks  down  and  gives 
way  under  pressure,  and  if  this  pressure  be  une- 
qually distributed,  bending  of  the  bones  and  altera- 
tion of  the  plane  of  the  joints  result. 

Rhachitis  is,  primarily,  a  constitutional  disorder, 
whose  local  manifestations  fall  with  greatest  force 
and  frequency  upon  the  organs  of  locomotion  and 
support,  the  bones,  the  epiphyses,  articular  surfaces 
of  the  joints,  the  ligaments,  and  muscles.  The 
osseous  changes  found  are  due  to  increased  vascu- 
larity of  the  periosteum  and  other  nutritive  centres, 
the  epiphyses,  and  medullary  substance.  Rhachitis 
is  a  disease  of  early  childhood.  Cases  in  which  it 
is  congenital  have  been  reported,  and  knock-knee 
and  bow-legs  have  been  observed  in  the  new-born. 
The  disease  most  usually  begins  about  the  period 
of  dentition,  and  is  attended  by  disturbances  in  the 
alimentary  tract,  vomiting  and  chronic  diarrhoea 
being  frequent.  The  patients  suffer  also  from 
sweating  of  the  head,  face,  and  neck,  and  prefer  to 
lie  quietly,  resisting  attempts  to  move  or  handle 
them.  With  this,  notable  weakness  and  marked 
tenderness  are  observed,  and  this  weakness,  notice- 
able chiefly  in  the  muscles,  sometimes  gives  rise  to 

16 


242  MEMOIR  OF  A.  S.  ROBERTS. 

a  condition  which  has  been  mistaken  for  infantile 
paralysis,  although  no  palsy  exists.  While  some 
children  suffering  from  rhachitis  appear  fairly  well 
nourished,  the  majority  have  a  large  belly,  and  a 
puffy,  flabby  condition  of  flesh,  easily  distinguished 
from  the  firm,  resistant  feeling  of  healthy  tissues. 
They  are  also  peculiarly  liable  to  convulsive  affec- 
tions, as  before  mentioned,  and  chronic  hydroceph- 
alus occurs  frequently.  Thirst  is  at  times  urgent ; 
the  patients  sit  or  lie  about ;  are  silent  or  drowsy, 
and  at  night  often  rest  upon  their  hands  and  knees, 
with  their  heads  buried  in  their  pillows,  or  toss  rest- 
lessly from  side  to  side. 

While  these  symptoms  are  progressing,  notable 
changes  are  going  on  in  the  bones,  muscles,  and 
ligaments.  I  have  already  alluded  to  these  changes 
in  my  general  remarks  on  pathology,  and  have 
shown  you  how  their  chief  expressions  are  found  in 
the  epiphyses  and  shafts  of  the  bones.  Clinically, 
it  is  not,  however,  alone  in  the  long  bones  that  the 
changes  take  place.  The  skull,  with  its  thin  and 
softened  envelope  and  thickened  sutures ;  the  thorax, 
as  shown  principally  in  the  beaded  ribs,  chicken- 
breast,  and  curved  vertebras,  and  the  flattened, 
distorted  pelvis,  all  bear  evidences  of  the  disease. 
Not  all  the  cases,  however,  exhibit  these  universal 
effects  of  the  general  condition.  Indeed,  I  have 
seen  undoubted  evidences  of  localized  rhachitis 
where  the  disease,  so  to  speak,  had  expended  itself 
upon  one  locality.  Thus,  it  is  not  unusual  to  see 
deformities  which  are  unilateral  in  character,  and 
one-sided  cases  of  bow-legs  and  knock-knee  are  not 


KNOCK-KNEE  AND  BOW-LEGS.  243 

uncommon.  We  have  already  spoken  of  the  causes 
which  produce  this  condition,  and  will  only  add 
that,  although  it  is  found  more  frequently  among 
the  poorer  classes,  the  wealthy  are  by  no  means 
exempt  from  it.  Poor  sanitary  surroundings,  insuffi- 
cient nourishment,  lack  of  air  and  sunlight,  and  the 
crowding  together  of  many  people,  frequent  preg- 
nancies, and  the  bringing  up  of  children  "  by  hand," 
all  add  their  quota  as  active  agents  in  its  produc- 
tion. Locality  and  climate  also  have  their  influence 
as  causative  factors.  Thus,  it  is  by  no  means  a 
common  disease  among  American  children,  but  is 
very  frequent  in  Southern  races,  the  negro  being 
peculiarly  liable  to  it ;  and  its  frequency  in  England 
has  caused  the  Germans  to  give  to  it  the  appellation 
of '" Englische  Kranlclieit" 

I  have  dwelt  at  length  upon  the  general  manifes- 
tations of  rhachitis  as  it  is  in  this  stage,  before 
local  symptoms  have  developed,  that  general  treat- 
ment may  prevent  deformity.  In  beginning  the 
treatment,  great  care  should  be  exercised  in  the 
selection  of  appropriate  diet,  and  all  errors  in  this 
and  the  surroundings  of  the  patient  should  be  cor- 
rected. The  child  should  be  regularly  taken  out  in 
the  open  air,  and  "sun-baths"  given.  Attention 
should  be  especially  directed  to  the  proper  bathing 
of  the  child,  and  the  skin  kept  in  good  condition  by 
these  means.  The  diet  should  be  digestible  and 
nutritious,  and  all  approved  methods  having  for 
their  object  the  proper  hygienic  care  of  the  patient 
should  be  persistently  and  systematically  employed. 
As  to  drugs,  those  which  are  directed  to  checking 


244  MEMOIR  OF  A.  S.  ROBERTS. 

the  diarrhoea  after  the  bowels  have  been  emptied 
of  irritating  matter  are  first  indicated.  The  time- 
honored  "  rhubarb-and-soda "  mixture  will  best 
accomplish  the  latter  purpose,  while  drop  doses  of 
tincture  of  opium,  with  the  addition  of  an  alkali, 
have  best  succeeded  in  my  hands  in  checking  the 
diarrhoea.  To  improve  the  general  condition  of  the 
child,  cod-liver  oil  may  be  given,  and  by  many  it  is 
considered  a  specific ;  but  there  are  many  objections 
to  its  use ;  it  is  apt  to  increase  the  digestive  trouble, 
and  many  children  cannot  be  induced  to  take  it,  no 
matter  how  disguised.  Good,  fresh  butter  answers 
admirably  as  a  substitute,  and  fulfils  all  the  indi- 
cations of  the  oil.  The  compound  syrup  of  the 
hypophosphites  is  another  excellent  remedy,  and  is 
readily  administered  for  a  long  time.  Iron  is  an 
efficient  tonic,  especially  the  syrup  of  the  hypophos- 
phite  or  the  iodide.  Phosphorus  also  has  given 
excellent  results  in  this  as  well  as  other  wasting 
diseases  of  the  bones.  Such  is  a  brief  outline  of 
the  medicinal  treatment  of  rhachitis,  important  in 
all  cases  of  the  disease,  but  most  important  in  cases 
prior  to  the  occurrence  of  deformity,  in  addition  to 
which  mechanical  supports  should  frecruently  be 
used  as  a  prophylactic  measure.  The  case  I  now 
show  you  will  illustrate  this  principle. 

Case  I.  Softening  of  the  bones  from  rhachitis; 
retention  braces  ;  improvement. — J.  M.,  aged  twenty- 
six  months.  The  hereditary  history  in  this  case  is 
good,  as  to  bone,  joint,  or  lung  troubles;  she  was 
apparently  healthy  until  her  eighth  month,  when 
her  mother  was  obliged  to  leave  her  to  the  care  of 


KNOCK-KNEE  AND  BOW-LEGS.  245 

strangers.  At  this  time  it  was  noticed  that  she 
was  not  as  lively  as  usual,  had  frequent  diarrhoea, 
was  peevish  and  restless  at  night,  sweating  freely, 
frequently  soaking  the  pillow.  She  has  never  at- 
tempted to  walk,  but  can  hold  herself  erect  by  the 
aid  of  chairs.  You  will  notice  the  flabby  condition 
of  the  muscles,  although  she  is  apparently  fairly 
nourished,  and,  although  presenting  all  the  char- 
acteristic symptoms  of  rhachitis — the  large  head, 
protuberant  belly,  and  flattened  epiphyses  indicate 
rhachitis — there  is,  as  yet,  no  evidence  of  deformity 
of  the  lower  extremities,  for  the  child  has  not  yet 
walked,  and  nature  has  evidently  acted  in  a  con- 
servative manner,  by  depriving  the  muscles  of  their 
proper  tone,  thereby  making  it  impossible  for  the 
child  to  throw  the  weight  of  the  body  upon  the 
lower  extremities,  and  we  have  happily  the  power 
to  prevent,  by  mechanical  means,  the  occurrence  of 
deviations  which  would  surely  follow  were  the  soft- 
ened osseous  tissues  allowed  to  bear  unaided  the 
superincumbent  weight  of  the  body. 

In  this  case  the  object  has  been  accomplished  by 
the  application  of  retention  braces,  consisting  of 
two  steel  uprights  fastened  to  the  shoe,  and  extend- 
ing above  the  knee,  with  joints  corresponding  to 
the  articulation  of  the  knee  and  ankle.  These  allow 
free  motion,  but  at  the  same  time  remove  the  super- 
incumbent weight.  To  one  point  I  wish  especially 
to  call  your  attention :  when  I  grasp  the  thigh  and 
leg  of  the  patient,  and  move  the  knee-joint  from 
side  to  side,  you  can  easily  distinguish  the  preter- 
natural lateral  mobility  of  the  articulation,  a  com- 


246  MEMOIR  OF  A.  S.  ROBERTS. 

mon  condition  in  rhachitic  subjects.  This  is  due  to 
ligamentous  relaxation,  and  opinions  vary  as  to  the 
ligaments  involved  and  their  action  in  the  produc- 
tion of  the  deformities,  it  being  considered  by  some 
that  primary  relation  of  the  internal  lateral  ligament 
results  in  a  separation  between  the  articular  surfaces 
of  the  knee-joint  upon  the  inner  side,  allowing 
increased  growth  of  the  internal  condyle  downward 
and  inward  in  the  gap  between  its  lower  surfaces  at 
the  head  of  the  tibia,  while  others  are  of  the  opinion 
that  shortening  of  the  external  lateral  ligament,  by 
permitting  pressure  to  be  exerted  upon  the  external 
condyle,  prevents  its  normal  growth,  the  internal 
condyle,  at  the  same  time,  completing  its  develop- 
ment. "While  some  cases  occur  in  which  ligament- 
ous relaxation  seems  to  be  the  only  apparent  cause 
of  the  deformity,  they  are  extremely  rare,  and  I 
think  that  the  relaxation,  as  a  rule,  is  secondary  to 
and  symptomatic  of  the  bony  changes.  While 
much  attention  has  been  given  to  the  external  liga- 
ments of  the  knee-joint  as  factors  in  the  causation 
of  knock-knee,  I  am  sure  that  the  internal  ligaments 
of  the  joint,  principally  the  crucial,  are  largely  con- 
cerned in  the  deformity;  but  as  to  the  mechanism 
of  these  ligaments  as  causative  agents,  I  cannot, 
for  want  of  time,  speak.  In  the  small  class  of  cases 
which  exhibit  no  evidence  of  rhachitis,  but  which 
suffer  from  relaxation  of  ligaments,  the  term  atonic 
can  best  be  applied.  They  are  similar  to  the  class 
of  lateral  spinal  curvatures  known  as  habitual  or 
functional ;  but,  as  before  stated,  in  the  majority  of 
cases  the  ligamentous  changes  are  secondary  to  the 


KNOCK-KNEE  AND  BOW-LEGS.  247 

osseous  ones,  and  depend  upon  the  general  condition, 
i.  e.,  rliacliitis. 

The  changes  which  occur  in  the  bones,  and  which 
lead  to  the  deformity,  may  be  divided  into  three 
stages : 

1.  Tlie  stage  of  vascularity,  or  invasion. 

2.  Tlie  stage  of  softening,  or  deformity. 

3.  The  stage  of  consolidation,  or  sclerosis. 

It  is  important  that  these  stages  should  be  recog- 
nized, as  giving  important  indications  for  treatment. 
The  second  stage  is  well  illustrated  in  the  case 
before  us :  when  I  grasp  the  limbs  and  attempt  to 
bend  the  bones,  a  characteristic  springy  sensation  is 
imparted  to  the  hands,  showing  that  the  stage  of 
softening  is  still  in  progress,  and  indicating  that 
constitutional  and  mechanical  treatment  are  suffi- 
cient. 

When  softening  has  further  progressed,  and  de- 
formity has  begun  from  the  weight  of  the  body 
upon  the  diseased  tissues,  mechanical  support  may 
still  suffice;  but  when  hardening  or  sclerosis  has 
once  occurred,  and  the  bones  are  in  a  deformed 
position,  nothing  but  operative  measures  will  re- 
store the  limb  to  its  normal  position.  To  determine 
this  stage  in  doubtful  cases  I  use  an  instrument 
which  I  look  upon  as  an  important  aid  to  correct 
diagnosis,  *".  e.,  the  ordinary  bone  drill,  preferably, 
the  cog-wheel  drill  of  Colin,  of  Paris ;  the  proced- 
ure is  analogous  to  exploratory  incision  prior  to 
other  surgical  operations.  Where  the  drill  encoun- 
ters no  obstacle  to  its  entrance  into  the  bone,  and 
imparts  to  the  hand  the  sensation  indicative  of  soft 


248  MEMOIR  OF  A.  S.  ROBERTS. 

tissue,  operative  procedures  are  not  necessary;  but, 
should  the  characteristic  resistance  of  the  sclerotic 
stage,  as  if  the  drill  were  being  bored  through 
ivory,  be  met,  mechanical  measures  will  be  futile, 
and  operation  is  necessary. 

I  have  an  opportunity  of  showing  you  another 
case  illustrative  of  the  stage  of  softening  with 
beginning  deformity. 

Case  II.  Bow-legs  from  rhachitis;  mechanical 
support;  improvement. — This  patient,  Mary  "W.,  is 
three  years  old;  gives  all  the  evidences  of  having 
had  rhachitis,  and  still  shows  symptoms  of  what 
may  be  called  the  subacute  stage.  You  notice 
many  of  the  conditions  to  which  I  called  your 
attention  in  speaking  of  the  child  who  has  just 
passed  out ;  but,  in  addition  to  these,  you  are  at 
once  struck  with  the  peculiar  waddling  gait,  and 
the  tendency  of  the  feet  to  a  varus  position  when 
the  child  attempts  to  walk.  This  varus  is  not  con- 
stant, as  in  some  cases  of  bow-legs  there  may  be  a 
valgoid  position  of  the  feet.  Here  you  again  see 
the  unusual  lateral  mobility  of  the  knee-joints.  In 
the  present  instance  the  deformity,  which  is  quite 
marked,  is  produced  by  curvatures  affecting  both 
the  femur  and  the  tibia ;  that  is  to  say,  the  rhachitic 
process  has  involved  the  diaphyses  above  and  below 
the  knee-joint.  This  is  not,  by  far,  as  common  as 
those  cases  where  the  tibia  is  alone  affected,,  in 
which  case  the  deformity  usually  takes  place  at 
about  the  middle  of  the  tibia,  although  the  same 
condition,  greatly  magnifying  the  distortion,  may 
occur  at  the  lower  third,  or  an  anterior  curvature 


KNOCK-KNEE  AND  BOW-LEGS.  249 

of  the  tibia  may  be  observed.  When  I  grasp  the 
bones  firmly  I  at  once  get  a  peculiar  springy 
response,  and  this  serves  as  a  guide  to  my  treat- 
ment in  this  stage.  In  answer  to  inquiry  concerning 
the  increase  of  the  deformity,  the  mother  states  that 
the  bowing  has  increased  very  rapidly  during  the 
last  four  or  five  months ;  that  before  this  it  was  not 
at  all  marked,  and  she  has  experienced  no  fear  of  a 
permanent  deformity,  having  been  told  by  a  practi- 
tioner that  the  child  would  surely  grow  out  of  it. 
This  is  a  popular  fallacy,  and  cannot  be  too  strongly 
condemned.  The  indications  for  mechanical  treat- 
ment are  therefore  very  plain.  In  order  to  counteract 
the  effect  of  the  superincumbent  weight  which  falls 
on  the  lower  extremities  during  the  day  in  the  act 
of  walking,  it  becomes  necessary  to  have  something 
which  shall  relieve  this,  and  for  this  purpose  I  use 
the  conventional  apparatus  which  I  briefly  described 
in  speaking  of  the  first  case.  This  brace  will  allow 
your  patient  to  go  about  at  the  minimum  risk  of 
increasing  the  deformity,  and  also  give  him  an 
opportunity  to  get  sunlight  and  fresh  air,  very  im- 
portant adjuncts  toward  improvement  of  his  general 
condition.  In  cases  in  which  deformity  is  present, 
this  serves  merely  as  a  retention  splint,  and  some- 
thing more  powerful  must  be  used  to  overcome  the 
deformity. 

The  brace  which  I  have  advised  for  the  applica- 
tion of  elastic  traction  has,  in  my  hands,  in  private 
and  hospital  practice,  accomplished  excellent  results. 
It  consists  of  a  piece  of  straight  tempered  steel,  its 
upper  extremity  terminating  in  a  semicircular  steel 


250 


MEMOIR  OF  A.  S.  ROBERTS. 


band  to  extend  half-way  around  the  limb ;  below, 
and  jointed  to  it  opposite  the  ankle,  is  a  steel  foot- 
piece  with  heel-cup,  which  is  secured  to  the  foot  by 
a  strap  passing  over  the  instep,  and  a  light  leather 
shoe-piece  laced  over  the  foot.  The  length  of  the 
upright  is  regulated  by  the  position  of  the  curva- 

Fig.  65. 


ture  in  the  bones  ;  in  bow-legs  where  this  occurs  in 
the  tibia,  the  upright  should,  therefore,  extend  only 
to  its  upper  border.  The  brace  is  adjusted  by 
securing  it  to  the  internal  aspect  of  the  limb,  and 
the  elastic  element  of  the  brace  brought  into  play 
by  strapping  the  steel  upright  to  the  leg  at  the 


KNOCK-KNEE  AND  BOW-LEGS.  251 

point  of  the  greatest  convexity  (Fig.  65).  It 
should  be  thus  applied  at  night,  and  it  is  readily 
seen  that  its  constant  effort  to  return  to  the  straight 
line  d  c  exerts  a  continuous  elastic  force  in  a  direc- 
tion calculated  to  reduce  the  deformity. 


LECTURE  II. 


Case  III.  Knock-knee;  application  of  elastic 
traction  brace. — Frances  G.  is  two  and  a  half  years 
old,  and  has,  as  the  father  states,  always  been  a 
weak,  nervous  child,  and  subject  to  croup.  During 
the  period  of  dentition  she  was  much  troubled  with 
diarrhoea,  and  very  thirsty ;  also  perspired  a  great 
deal,  and  was  restless  and  peevish.  The  ribs  have 
the  "  beaded "  feel ;  there  is  quite  a  prominent 
sternum,  and  all  the  epiphyses  are  flattened.  The 
skull  also  shows  evidences  of  rhachitis.  On  placing 
the  child  on  her  feet,  the  deformity  of  the  lower 
extremities,  consisting  principally  of  the  in-knee 
deviation,  is  at  once  perceived.  There  is  the  usual 
extensive  lateral  motion  at  the  knee-joints  which  is 
also  manifested  in  the  other  articulations.  When  I 
flex  the  legs  on  the  thighs  the  deformity  disappears ; 
there  is  marked  projection  at  the  inner  side  of  the 
knees,  due  to  the  hypertrophied  internal  condyle  of 
the  femur.  The  first  thing  that  attracts  attention 
to  these  cases  is  the  peculiar  gait  when  the  children 
begin  to  walk,  which  they  do  not  attempt,  as  a  rule, 
until  quite  late,  and,  with  this,  much  fatigue  is  com- 
plained of.     Pain  is  not  a  frequent  or  urgent  symp- 


252 


MEMOIR  OF  A.  S.  ROBERTS. 


torn,  and,  when  it  occurs,  is  referred  to  the  inner  side 
of  the  knee. 

In  the  treatment  of  this  case  the  same  rules 
should  be  followed  as  are  applicable  to  the  cure  of 
bow-legs;  and  as  sclerosis  has  not  as  yet  occurred, 

Fig.  66. 


I  shall  use,  in  addition  to  the  retention  braces  to  be 
worn  throughout  the  day,  an  elastic  traction  brace 
at  night.     (Fig.  66.) 

It  is  applied  to  the  external  aspect  of  the  limb, 
and  the  upright  extends  well  up  to  the  thigh,  and  is 
secured  at  two  points,  just  above  and  just  below 


KNOCK-KNEE  AND  BOW-LEGS.  253 

the  knee-joint,  so  that,  in  its  efforts  to  right  itself, 
it  will  produce  continuous  elastic  pressure  upon  the 
foypeiiropliied  internal  condyle.  It  would  be  impos- 
sible in  a  clinical  lecture  for  me  to  describe  exten- 
sively the  various  forms  of  apparatus  devised  for 
the  relief  of  this  deformity,  but  among  others  used 
for  removing  it  are  those  which  aim  at  this  result 
by  the  use  of  exaggerated  interarticular  pressure 
directed  against  the  already  hypertrophied  internal 
condyle,  thus  attempting  to  produce  absorption  at 
this  point.  This  also  involves  the  use  of  intermit- 
tent rather  than  constant  pressure.  I  am  of  the 
opinion  that,  while  intermittent  traction  through  soft 
tissues  is  of  infinite  value  in  the  relief  of  certain 
deformities,  this  does  not  hold  concerning  intermit- 
tent pressure.  Apart  from  the  fact  that  these 
instruments  are  complicated  and  expensive,  difficult 
of  adjustment,  and  liable  to  constant  malposition  by 
slipping,  etc.,  they  must  depend  largely  for  their 
efficacy  on  the  constant  personal  supervision  of  the 
surgeon  or  attendant.  Again,  the  fallacy  of  attempt- 
ing to  produce  absorption  by  intermittent  pressure 
from  without  is  clearly  shown  by  Sir  James  Paget, 
in  his  "  Lectures  on  Pathology,"  who,  in  speaking 
of  atrophy  as  manifested  in  the  Chinese  foot,  and 
also  in  stumps  after  amputation,  says :  "  These 
examples,  then,  may  suffice  to  show,  as  I  have  said, 
that  constant  pressure  on  a  part  produces  absorp- 
tion; occasional  pressure,  especially  if  combined 
with  friction,  produces  thickening  or  hypertrophy, 
and  that  these  result  whatever  be  the  direction  of 
the  pressure." 


254 


MEMOIR  OF  A.  S.  ROBERTS. 


The  positive  atrophy  and  absorption  of  tissues 
from  elastic  pressure,  on  the  contrary,  are  remark- 
ably shown  in  the  destruction  and  removal  of  large 
areas  of  bone,  which  frequently  occur  in  aneurism 
of  the  aorta,  and  this  brace  is  constantly  exerting  a 
similar  influence  upon  the  internal  condyle. 

Case  IV.  Unilateral  genu  valgum;  osteotomy  ; 
cure. — The  next  case  is  one  upon  which  I  operated 

Fig.  67. 


at  the  clinic  a  few  weeks  ago,  and  is  the  first  oste- 
otomy for  genu  valgum  performed  at  this  hospital. 


KNOCK-KNEE  AND  BOW-LEGS. 


255 


Frank  D.,  aged  five,  colored,  an  inmate  of  the 
children's  ward,  presented  the  following  character- 
istic rhachitic  deformities  :  The  vertebrae  are  rotated 
upon  their  axis,  and  laterally  deflected  into  the 
deformity  of  rotary  lateral  curvature  and  rhachitis, 
the  primary  curve  existing  in  the  lumbar  region. 


Fig. 


The  deformity  of  the  lower  extremity  presented  as 
a  unilateral  genu  valgum  of  the  left  limb.  The 
femur  is  markedly  curved  in  an  anterior  and  lateral 
direction,  the  internal  condyle  being  depressed  below 
the  normal  plane  of  the  joint,  producing  a  decided 


256  MEMOIR  OF  A.  S.  ROBERTS. 

in-knee  deviation,  as  seen  in  Fig.  67,  taken  from  a 
photograph  prior  to  the  operation.  The  duration 
and  pronounced  character  of  the  deformity  appar- 
ently render  this  patient  a  fit  subject  for  the  opera- 
tion of  osteotomy  or  subcutaneous  fracture  of  the 
bone  for  restoration  of  the  limb  to  a  normal  position. 
Yet  in  order  to  be  perfectly  sure  that  the  stage  of 
softening  had  passed,  and  that  nothing  more  was  to 
be  expected  from  conservative  mechanical  treat- 
ment, I  made  use  of  the  bone-drill  spoken  of,  before 
operating,  and  finding  all  the  indications  of  sclerosis 
present,  I  performed  the  operation  of  osteotomy, 
and  am  happy  to  show  you  the  correction  of  the 
deformity  as  seen  by  these  photographs,  made  prior 
and  subsequent  to  the  operation.  (See  Figs.  67 
and  68.) 

Before  proceeding  to  my  next  case,  I  think  it  will 
be  well  briefly  to  call  your  attention  to  the  different 
surgical  procedures  now  in  vogue  for  the  relief  of 
these  deformities,  and  also  to  a  short  historical 
account  of  them.  These  may  be  placed  under  three 
heads,  as  follows : 

1.  Forcible  straightening. 

2.  Osteoclasis. 

3.  Osteotomy. 

Of  the  first  two  mentioned  methods,  I  will  not 
enter  into  detail.  They  are  approved  by  many  sur- 
geons,  especially  the  French,  and  successful  cases 
have  been  reported  as  having  been  brought  about 
by  these  means ;  Delore,  of  Lyons,  and  Tillaux 
being  their  principal  advocates.  Excellent  osteo- 
clasis havo  also  been  devised  by  Colin  and  Robin. 


KNOCK-KNEE  AND  BOW-LEGS.  257 

The  brilliant  results  attained  by  osteotomy  have, 
however,  given  this  operation  the  palm,  and  most 
surgeons  now  perform  this  in  preference  to  osteo- 
clasis. 

Although  osteotomy  for  an  anchylosed  hip-joint 
had  been  performed  by  Khea  Barton,  of  this  city, 
as  early  as  1826,  it  was  not  until  1852  that  Mayer, 
of  Hamburg,  first  operated  for  knock-knee.  He 
opened  the  joint  in  his  operation,  and  one  of  his 
cases  died  of  tetanus.  In  the  same  year  Langen- 
beck  proposed  osteotomy  in  cases  of  anchylosed 
knee.  Following  this  many  osteotomies  of  different 
articulations  were  performed,  and  American  sur- 
geons, Pancoast,  Sayre,  and  Brainard,  were  among 
the  first  to  practise  them.  As  applied  to  the  de- 
formity genu  valgum,  the  first  operator  in  England 
was  Annandale,  who  virtually  excised  a  part  of  the 
condyles  of  the  femur  for  knock-knee,  the  operation 
being  done  under  antiseptic  precautions.  Anti- 
septic osteotomy  was  introduced  by  Volkmann,  of 
Halle,  in  1875,  the  same  year  that  Annandale  ope- 
rated. In  1876,  Ogston  performed  the  operation, 
using  the  saw,  and  was  followed  by  Schede,  of 
Berlin.  The  objection  to  all  these  operations  was 
the  fact  that  the  knee-joint  was  opened,  exposing 
the  patient  to  even  a  greater  danger  than  the  origi- 
nal deformity.  In  1877  Chiene  cut  through  the 
condyle  with  a  chisel,  removing  a  wedge-shaped 
piece.  In  1878  Barwell  performed  his  "simul- 
taneous multiple  osteotomy,"  which  consisted  in  a 
division  of  both  femur  and  tibia.  In  1878  Mac- 
ewen   introduced   his    supra-condyloid   osteotomy, 

17 


258 


MEMOIR  OF  A.  S.  ROBERTS. 


and  this,  involving  no  possible  danger  to  the  knee- 
joint,  has  been  popularly  adopted.  In  1S79  Keeves 
modified  Ogston's  operation  so  that  the  danger  of 
opening  the  articulation  was  reduced  to  the  mini- 
mum, the  object  being,  at  the  same  time,  to  replace 
the  displaced  condyle.  The  following  diagram 
(Fig.  69)  will  illustrate  the  various  points  of  elec- 
tion for  the  performance  of  osteotomy. 


Fig.  69. 


1.  Mayer,  Billroth,  Schede.     2.  Annandale.     3.  Ogston,  Reeves, 
Chiene.     4.  Maceweu.     5.  Taylor. 

Of  all  the  operations  mentioned,  I  give  my  per- 
sonal preference  to  that  of  Macewen,  and  in  the 
case  which  I  now  present  to  you,  propose  to  perform 
the  operation. 


KNOCK-KNEE  AND  BOW-LEGS. 


259 


Case  \.  Bilateral  knock-knee;  double  osteotomy 
by  Maceweri's  method;  recovery. — The  history  in 
brief  is  as  follows :  Lottie  H.,  aged  five,  colored, 
was  admitted  into  the  Philadelphia  Hospital  in 
1881,  suffering  from  severe  bilateral  knock-knee. 
No  record  could  be  obtained  of  her  previous  history 

Fig.  70. 


or  the  time  at  which  the  deformity  first  appeared. 
You  will  notice,  however,  that  a  marked  curvature 
or  in-knee  deviation  exists  in  both  lower  extremities 
(Fig.  70).  The  femora  have  an  anterior  bend  in 
their  lower  third,  as   well   as   a   lateral  deviation. 


260  MEMOIR  OF  A.  S.  ROBERTS. 

Curves  of  similar  character  are  present  in  the  tibia. 
On  measurement,  I  find,  when  the  internal  condyles 
of  the  femur  are  approximated,  the  malleoli  at  the 
ankle-joint  are  separated  nine  and  a  half  inches,  as 
shown  in  Fig.  70,  from  a  photograph.  On  account 
of  the  long-standing  and  pronounced  character  of 
the  deformity,  having  satisfied  myself  by  the  drill 
that  sclerosis  has  taken  place,  I  propose  to  do  a 
double  supra-condyloid  osteotomy,  after  the  plan 
recommended  by  Macewen,  of  Glasgow. 

The  patient  being  anaesthetized,  and  having 
cleansed  the  limbs  and  rendered  them  aseptic  at 
the  point  of  election  for  the  introduction  of  the 
osteotome,  the  elastic  roller  of  Esmarch  is  applied, 
and  the  limbs  rendered  bloodless.  After  securing 
the  vessels  by  a  few  turns  of  rubber  tubing,  the 
bandages  are  removed,  and  the  limbs  are  ready  for 
puncture,  which  is  made  at  a  point  two  fingers' 
breadth  above  the  internal  condyle.  The  osteotome 
is  now  introduced  down  to  the  bone,  and  turned 
transversely  to  the  long  axis  of  the  shaft.  By  a 
few  blows  of  a  heavy  wooden  mallet,  the  instru- 
ment is  driven  through  the  bone,  and  then  with- 
drawn from  the  wound,  a  little  force  being  now 
required  to  complete  the  fracture.  Now  loosen  the 
turns  of  the  rubber  tubing,  to  ascertain  if  any 
hemorrhage  has  taken  place,  and,  as  you  see,  this  is 
very  slight  and  mostly  venous.  The  punctures  are 
dusted  with  iodoform,  and  covered  with  pledgets  of 
lint  that  have  been  previously  soaked  in  compound 
tincture  of  benzoin,  which  quickly  dries,  forming 
an  excellent  artificial   seal.     The  next  step  is   to 


KNOCK-KNEE  AND  BOW-LEGS. 


261 


envelop  the  limbs  in  a  flanner  roller,  and  place  over 
all  the  plaster-of-Paris  bandage  from  the  toes  to  the 
upper  third  of  the  thigh.  It  is  well  always  to  have 
the  plaster  thoroughly  dried  in  an  oven  overnight, 


Fig.  71. 


From  a  photograph  taken  six  months  after  operation,  showing 
correction  of  deformity. 


as  it  facilitates  its  setting  and  makes  a  much  stiffer 
and  more  durable  splint;  while  the  plaster  is  setting, 
the  limbs  are  "over-straightened,"  and  the  knees 
brought  in  a  position  of  slight  genu  varum,  by 


262  MEMOIR  OF  A.  S.  ROBERTS. 

placing  a  roller  bandage  between  them,  and  bring- 
in  gs  the  malleoli  together.  Three  days  from  the 
date  of  operation  I  shall  cut  a  small  fenestrum  in 
the  dressing  opposite  the  point  of  puncture,  and 
examine  the  wound.  Should  no  unfavorable  symp- 
toms intervene — i.  e.,  suppuration  or  retarded  union 
— the  dressing  will  be  removed  at  the  end  of  six 
weeks,  and  the  patient  placed  upon  her  feet  with 
light  steel  retention-braces,  jointed  at  the  knee  and 
ankle,  to  allow  of  motion. 

Before  closing,  I  desire  to  say  a  few  words  upon 
the  other  causes  of  knock-knee  and  bow-legs  men- 
tioned in  the  early  part  of  this  lecture.  Disturbance 
of  trophic  centres  acting  either  upon  muscular  tissue, 
destroying  equilibrium,  or  upon  the  nutrition  of  the 
epiphyses,  has  been  assigned  as  a  cause  of  knock- 
knee  and  bow-legs.  The  most  direct  results  of 
central  disturbance  are  seen  in  connection  with 
poliomyelitis  anterior  (infantile  spinal  paralysis), 
and  in  tetanoid  or  spastic  paraplegia.  Here  de- 
formity is  induced  directly  by  the  lack  of  supporting 
power  in  the  muscles,  as  well  as  the  loss  of  tone  in 
the  ligaments,  and  cannot  be  explained  by  the  old 
antagonistic  theory  of  loss  of  power  in  one  set  of 
muscles,  with  preponderating  action  in  others.  The 
same  conditions  obtain  which  Volkmann  had  shown 
to  exist  in  the  production  of  club-foot,  the  deformity 
not  resulting  from  loss  of  muscular  antagonism,  but 
rather  from  growth  while  the  part  remains  in  an 
abnormal  position.  It  is  also  probable  that  in  these 
paralytic  cases  the  changes  brought  about  in  nutri- 
tion affect  the  bone  to  a  large  extent,  as  it  has  been 


KNOCK-KNEE  AND  BOW-LEGS.  263 

shown  that  they  are  much  thinner,  more  curved, 
and  softer  than  normal.  Here  we  cannot  say  that 
rhachitis  enters  as  an  etiological  factor,  owing  to 
the  absence  of  its  characteristic  symptoms. 

The  fact  that  cases  of  unilateral  in-knee  deviation 
are  often  observed  without  the  association  of  symp- 
toms denoting  the  presence  of  rhachitis  has  given 
rise  to  the  idea  that  there  is  a  condition  which 
affects  the  nutrition  of  the  epiphyses  in  such  a 
manner  as  to  produce  knock-knee,  and  that  this  is 
a  probable  result  of  central  changes  having  their 
expression  in  the  epiphyseal  cartilages  of  the  knee- 
joint.  This  is  purely  theoretical,  though  not  an 
entirely  groundless  idea. 

I  have  thus  endeavored  to  give  you  concisely  the 
principal  points  in  the  pathology  and  treatment  of 
bow-legs  and  knock-knee,  and  hope  that,  with  the 
general  indications  I  have  attempted  to  impress, 
you  will  be  enabled  to  cope  successfully  with  these 
deformities. 


FLAT-FOOT: 


A  NEW  PLANTAR  SPRING  FOR  ITS  RELIEF. 


FLAT-FOOT : 
A  NEW  PLANTAR  SPRING  FOR  ITS  RELIEF. 


Amoistg-  the  most  distressing  and  painful  deform- 
ities of  the  lower  extremity  which  the  orthopedic 
surgeon  is  called  upon  to  treat,  cases  of  flat-foot 
stand  foremost.  I  should  not  have  ventured  to 
speak  of  this  very  common  deformity  did  I  not 
think  that  its  importance  is  often  overlooked,  and 
that  in  many  instances  it  is  a  source  of  much  con- 
fusion regarding  its  etiology,  diagnosis,  and  treat- 
ment, to  those  who  have  not  had  many  opportunities 
for  studying  the  disease. 

As  a  rule,  the  ordinary  forms  of  club-foot  are 
unattended  with  pain ;  this  sympton  entering  only 
secondarily,  either  as  a  result  of  pressure  from 
walking  in  the  deformed  position,  or  from  the  faulty 
mechanical  appliances  used  to  correct  the  deformity. 
In  the  form  of  talipes  under  consideration,  however, 
pain  plays  an  important  part,  and  with  this  the  dis- 
ability produced  is  often  so  extreme  as  to  render 
the  patient  unable  to  pursue  his  ordinary  occupa- 
tion. Thus,  in  addition  to  the  usual  end  to  be 
attained  in  the  treatment  of  deformities  of  the  feet, 
namely,  the  restoration  to  the  normal  form  of  the 


268  MEMOIR  OF  A.  S.  ROBERTS. 

foot,  we  have  another  and  more  practical  object  de- 
manding onr  utmost  attention  and  study,  and  that 
is  the  preservation  of  the  means  of  livelihood  to 
those  who  are  unfortunately  afflicted  with  flat-foot. 

Like  other  forms  of  talipes,  flat-foot,  or  talipes 
valgus,  may  be  a  congenital  or  an  acquired  malfor- 
mation, but  it  is  very  rarely  found  at  birth  to  such 
an  extent  as  to  be  considered  pathological.  On  the 
other  hand,  the  acquired  forms  of  valgus,  taking  all 
the  varieties  collectively  —  whether  occurring  as 
simple  flattening  of  the  arch,  as  secondary  to  rha- 
chitis,  as  the  result  of  infantile  spinal  paralysis,  or 
those  of  the  inflammatory  type — talipes  valgus 
probably  occurs  most  frequently  of  all  the  distor- 
tions of  the  feet. 

It  may  be  well,  in  this  connection,  before  proceed- 
ing to  an  account  of  the  etiology  of  talipes  valgus, 
to  give  a  brief  account  of  the  normal  mechanism  of 
the  foot  and  of  the  plantar  arch.  All  of  that  portion 
of  the  lower  extremity  situated  below  the  tibio-tarsal 
articulation  enters  into  the  construction  of  the  foot, 
and  in  the  adult  has  the  form  of  an  arch,  with  its 
convexity  or  dorsal  surface  above  and  its  concavity 
or  plantar  surface  below.  At  the  highest  point  of 
this  arch,  which  is  formed  by  the  astragalus,  the 
weight  of  the  body  is  received  and  transmitted ; 
receiving  the  weight  on  its  trochlear  surface  from 
the  tibia,  and  transmitting  it  through  the  so-called 
pillars  of  the  arch.  Of  these  there  are  two,  the 
anterior  one,  composed  of  the  scaphoid,  three  cunei- 
form and  the  three  inner  metatarsal  bones,  being 
the    longer,  less   oblique,  and    more   elastic.     The 


■FLAT-FOOT.  269 

posterior  pillar,  formed  by  the  os  calcis,  is  shorter 
and  thicker,  its  concavity  being  directed  inward, 
and  it  is  less  elastic  than  the  anterior  one.  The 
astragalus,  therefore,  may  be  regarded  as  the  key- 
stone of  the  arch ;  but  it  differs  in  certain  respects 
from  the  keystone  of  the  ordinary  arch.  While  its 
anterior  surface,  by  its  apposition  to  the  concave 
posterior  surface  of  the  scaphoid,  fulfils  this  re- 
quirement, posteriorly  it  rests  upon  and  overrides 
the  os  calcis.  Hence,  this  weak  point  in  the  arch 
has  to  be  supplemented,  so  to  speak,  and  this  is 
accomplished  by  the  soft  parts,  the  interosseous 
ligaments  passing  between  and  binding  together 
the  bones,  the  calcaneo-scaphoid  ligaments  arising 
from  the  inferior  surface  and  forepart  of  the  os 
calcis,  and  passing  to  the  posterior  and  under  part 
of  the  scaphoid  bone,  thus  giving  direct  support  to 
the  head  of  the  astragalus.  Again,  we  have  a 
secondary  arch  supporting  the  primary  one.  This 
is  formed  by  the  outer  part  of  the  os  calcis,  the 
cuboid,  and  the  two  outer  metatarsal  bones,  this  sup- 
plementary arch  being  supported  by  the  calcaneo- 
cuboid ligaments,  while  the  strong  plantar  fascia 
extends  between  and  acts  as  a  brace  to  the  pillars 
of  the  arch.  It  must  not  be  forgotten  that,  while 
an  arch  has  ordinarily  to  receive  weight  only  in  one 
direction,  in  the  case  of  the  foot  the  direction  of 
the  weight  is  continually  changed  by  the  various 
positions  assumed  by  the  bod}r  in  its  movements. 
Thus,  while  in  the  standing  position  the  weight 
would  fall  chiefly  on  the  astragalus  and  be  directly 
transmitted  to  the  two  pillars  of  the  arch,  in  walk- 


270  MEMOIR  OF  A.  S.  ROBERTS. 

ing,  running,  dancing,  etc.,  involving,  as  these  move- 
ments do,  the  different  parts  of  the  foot,  the  weight 
is  constantly  shifted,  and  consequently  the  liga- 
ments and  muscles  of  the  foot  are  called  upon  to 
reinforce  the  arch  by  their  action.  Added  to  this 
there  is  the  mobility  of  the  tarsus,  and  this  mobility 
is  the  greatest  just  where  the  greatest  strain  falls, 
namely,  between  the  astragalus  and  scaphoid.  The 
muscle  principally  called  upon  in  this  connection  is 
the  tibialis  posticus,  while  the  inner  part  of  the 
calcaneo-scaphoid  ligament  is  chiefly  engaged  in 
resisting  all  extra  strain. 

It  will  be  easily  understood  then,  that,  associated 
with  the  different  complex  movements  alluded  to, 
involving  as  they  do  the  raising  (flexion)  and 
placing  of  the  foot  on  the  ground  (extension),  on 
the  resistance  offered  by  the  tibialis  posticus  and 
calcaneo-scaphoid  ligament,  and  upon  the  help  thus 
given  to  the  arch,  depend  the  conservation  of  the 
form  of  the  foot.  Again,  the  normal  curves  of  the 
foot  give  a  certain  amount  of  mechanical  advantage 
in  the  distribution  of  the  superincumbent  body 
weight.  Thus,  in  flexion  the  two  curves  of  the 
foot — the  larger,  with  its  concavity  downward,  and 
a  lesser  one  along  the  inner  side  of  the  foot,  with 
its  concavity  outward — are  increased.  On  the  other 
hand,  in  extension,  as  when  the  foot  is  firmly 
planted  on  the  ground,  both  these  curves  are  dimin- 
ished and  the  foot  is  flattened.  It  is  evident,  there- 
fore, that  any  cause  operating  to  weaken  those 
tissues  which,  by  their  aid,  serve  to  strengthen  the 
arch,  will  cause  a  permanent  extension  of  the  foot, 


FLAT-FOOT.  271 

with  obliteration  of  the  natural  curves.  Thus,  in 
occupations  requiring  continued  standing  or  walk- 
ing, or  the  maintenance  of  a  given  position  for  a 
long  time,  these  structures  become  overtaxed,  and, 
as  a  consequence,  do  not  afford  the  proper  accessory 
support  to  the  arch ;  there  exists  a  condition  of  per- 
manent extension  of  the  foot,  and  sooner  or  later, 
depending  on  the  constitution  of  the  individual, 
flat-foot  follows  as  a  consequence  of  this  abnormal 
strain. 

The  morbid  anatomy  of  flat-foot,  or  spurious 
valgus,  shows  differences  according  to  the  etiology 
of  the  given  cases.  Thus,  in  the  congenital  variety 
very  few  pathological  changes  are  noticeable.  The 
external  appearance  of  the  foot  shows  a  decided 
lowering  or  flattening  of  the  normal  arch,  with  the 
inner  margin  of  the  foot  depressed  and  closer  to  the 
ground,  while  the  outer  border  is  raised,  and  the 
anterior  part  of  the  foot  everted.  Sometimes  in 
these  congenital  cases  there  is  a  marked  degree  of 
equinus  associated  with  the  valgus,  and  when  this 
occurs  there  is  decided  contraction  of  the  calf 
muscles.  In  the  congenital  form  of  valgus  there  is 
not  much  displacement  of  the  bones  of  the  foot,  the 
principal  changes  consisting  of  the  elevation  of  the 
tuberosity  of  the  os  calcis,  while  the  astragalus  is 
pushed  downward  and  forward,  and  is  seen  as  a 
prominence  on  the  inner  side  of  the  foot,  with  the 
rotated  scaphoid  bone,  which  is  also  prominent. 
There  is  a  slight  rotation  outward  of  the  cuboid 
bone,  and  the  malleoli  are  depressed,  being  found 
on  a  lower  plane  than  normal.     The  weight  of  the 


272  MEMOIR  OF  A.  S.  ROBERTS. 

body  coming  on  these  disturbed  relations  is  not 
properly  received  and  transmitted,  and,  as  a  conse- 
quence, the  strain  becoming  too  severe  on  those 
tissues  which  serve  to  assist  the  arch,  there  is  a 
resulting  stretching  of  the  ligaments  on  the  plantar 
and  inner  side  of  the  foot.  Thus  the  calcaneo- 
scaphoid  ligament  especially,  which  bears  the  brunt 
of  resistance  to  displacement,  and  is  constantly 
called  upon  in  this  connection,  becomes  relaxed.  In 
the  congenital  form,  although  the  muscles  show  few 
changes,  with  the  continuance  of  the  affection  there 
often  ensues  a  marked  contraction  of  the  peronei 
and  calf  muscles,  the  foot  then  taking  the  form  of 
an  equino-valgus.  With  this  there  is  often  found 
a  contraction  of  the  extensor  longus  digitorum,  the 
extensor  pollicis,  and  the  abductor  minimi  digiti, 
with  slight  alterations  in  the  relations  of  all  the 
tendons  of  these  muscles. 

The  forms  of  flat-foot  which  deserve  most  of  our 
attention  will  come  under  those  found  in  the  ac- 
quired variety,  and  these  are  the  cases  which,  from 
the  unusual  suffering  and  disability  they  occasion, 
constitute  a  large  and  important  class.  They  have 
been  variously  called  "  splay-foot,"  "  spurious  val- 
gus," "  inflammatory  flat-foot,"  "  the  tarsalgia  of 
adolescents,"  etc.  In  children  the  acquired  form  of 
valgus  usually  met  with  is  the  result  of  a  poliomye- 
litis anterior,  and  in  this  condition  the  anterior  tibial 
and  adductor  muscles  are  usually  the  paralyzed 
ones.  At  times,  as  in  the  congenital  form,  there  is 
a  coincident  contraction  of  the  calf  muscles,  render- 
ing the;  deformity  a  compound  one,  and  we  have  a 


FLAT-FOOT.  273 

talipes  equino-valgus.  It  is  also  found  very  often 
associated  with  knock-knee  and  bow-legs,  as  a 
mechanical  result  of  these  deformities,  especially  in 
rhachitic  subjects.  Rhachitis  itself  is  a  very  pro- 
lific source  of  this  deformity,  while  as  a  symptom- 
atic condition  in  ankle-joint  disease,  after  injuries 
and  burns  of  the  foot,  and  following  rheumatism, 
flat-foot  is  of  frequent  occurrence. 

Each  one  of  these  causes  must  be  made  out  and 
its  relations  to  the  deformity  closely  studied,  but 
the  limit  of  this  paper  is  too  short  to  give  an 
extensive  account  of  each  variety.  It  is  the  condi- 
tion variously  named,  as  already  stated,  that  I  wish 
to  emphasize  particularly. 

While  to  the  experienced  orthopedist  flat-foot  is 
not  especially  difficult  of  detection,  to  one  who  has 
not  seen  many  cases  it  frequently  presents  puzzling 
symptoms.  Thus,  it  is  frequently  mistaken  for 
neuralgia,  rheumatism,  and  even  for  chronic  osteitis 
of  the  tarsal  bones,  and  I  have  had  patients  who 
have  been  treated  for  all  these  conditions  before 
the  real  cause  was  diagnosticated.  They  are  met 
with  generally  at  the  period  of  adolescence,  although 
I  have  had  several  cases  in  which  the  patients  were 
between  forty  and  sixty  years  of  age.  In  occupa- 
tions necessitating  long  continuance  of  one  position, 
as  is  the  case  in  bakers,  machinists,  clerks,  waiters, 
weavers,  or  in  those  vocations  which  compel  con- 
stant and  fatiguing  motion,  as  in  soldiers,  the  de- 
formity happens  frequently.  Growing  boys  and 
girls,  especially  those  of  a  languid  disposition  with 
a  tendency  to  the  accumulation  of  adipose  tissue, 

18 


274  MEMOIR  OF  A.  S.  ROBERTS. 

are  more  liable  to  this  painful  trouble.  Certain 
races  seem  prone  to  this  affliction,  namely,  the 
neoro  and  the  Jewish  races. 

The  gait  and  attitude  of  patients  suffering  with 
this  trouble  are  characteristic  and  easily  recognized. 
They  have  a  heavy,  dragging  gait,  the  knees  being 
bent,  and  the  feet  are  placed  in  a  careful,  gingerly 
way  on  the  ground,  so  that  all  the  weight  possible 
shall  be  kept  from  the  tender  part.  When  such 
patients  step  on  an  uneven  surface  the  pain  com- 
plained of  is  of  an  excruciating  nature,  and  walking 
or  standing  is  avoided  as  much  as  possible.  The 
patients  are  easily  tired,  and  .have  an  anxious 
expression  of  countenance,  the  general  condition 
sympathizing  to  such  an  extent  with  the  local 
trouble  that,  in  certain  instances,  the  nutrition  of 
the  patient  suffers  very  markedly.  This  is  not  diffi- 
cult to  understand  when  we  reflect  that,  occurring 
as  it  does  in  young  people  generally  active,  and  at 
a  time  of  life  when  the  desire  for  exercise  and  enjoy- 
ment is  at  its  height,  the  enforcement  of  compara- 
tive idleness  by  the  pain  experienced  prevents  the 
proper  completion  of  those  functions  which  give  the 
system  at  large  its  elasticity  and  tone. 

The  morbid  changes  found  in  the  acquired  form 
of  flat-foot  are  those  which  are  found  associated 
with  the  special  etiological  factors  entering  into  the 
production  of  the  deformity.  For  a  long  time  it 
was  supposed  that  the  painful  variety,  in  which  we 
are  especially  interested,  was  due  to  an  osteitis,  but 
no  absolute  evidence  of  an  inflammatory  lesion, 
such,  for  instance,  as  that  seen  in  the  head  of  the 


FLAT-FOOT.  275 

femur  in  morbus  coxarius,  has  been  found.  Still,  I 
have  seen  cases  in  which,  on  rotation  of  the  tarsus, 
marked  reflex  spasm  of  the  abduction  muscles  was 
occasioned.  If  any  osteitis  be  present,  it  would 
seem  to  me  to  be  of  the  nature  of  dry,  or  caries 
sicca.  In  none  of  the  cases  that  I  have  seen  have 
there  been  evidences  of  suppuration,  the  local 
symptoms  at  times  showing  swelling,  especially 
below  the  malleoli,  with  a  semi-fluctuating  feeling ; 
but  heat  is  generally  absent.  On  the  contrary,  the 
feet  of  flat-footed  people  are,  as  a  rule,  cold,  and 
have  a  peculiar,  dark-blue  look,  as  though  the 
venous  circulation  was  badly  accomplished.  The 
appearances  of  the  bones  are  such  that  pressure 
in  the  deformed  position  would  amply  account  for 
them.  They  are  not  especially  altered  in  their  rela- 
tive positions,  although,  with  the  gradual  falling  of 
the  arch,  the  astragalus  becomes  slightly  displaced 
downward,  the  scaphoid  and  internal  cuneiform 
bones  being  brought  to  a  lower  plane  than  normal 
and  nearer  the  ground.  It  is  at  the  inner  side  of 
the  foot  where  the  astragalus  and  scaphoid  show 
prominently,  that,  as  a  rule,  the  greatest  amount  of 
pain  is  experienced ;  but  the  location  of  the  pain  is 
by  no  means  constant,  the  transverse  tarsal  joint, 
the  metatarsophalangeal  articulation,  and  even  the 
calcaneum  being  at  times  the  seat.  With  the  con- 
tinuance of  the  abnormal  pressure  and  the  bony 
changes  due  to  it,  there  is  seen  a  gradual  destruc- 
tion of  the  normal  arch.  The  abductor  muscles 
begin  to  contract  strongly,  while  the  adductors  are 
in  a  condition  of  functional  paresis,  and  thus,  added 


276  MEMOIR  OF  A.  S.  ROBERTS. 

to  the  flattening  of  the  foot,  we  have  abduction  and 
a  constant  condition  of  extension ;  and  if  the  con- 
traction of  the  abductor  muscles  be  maintained,  the 
outer  edge  of  the  foot  is  raised  and  does  not  touch 
the  ground.  In  the  extreme  degrees  of  the  affection 
the  instep  becomes  totally  obliterated  through  the 
loss  of  the  convexity  of  the  arch,  and  the  internal 
malleolus  especially  becomes  more  and  more  promi- 
nent, and  is  seen  with  the  protuberant  astragalus 
and  scaphoid  bones  as  a  prominence  on  the  inner 
side  of  the  foot. 

In  this  condition,  I  have  found,  taking  the  medio- 
tarsal  joint  as  a  base  line  of  measurement,  and 
erecting  upon  this  a  perpendicular  corresponding  to 
the  long  axis  of  the  os  calcis,  that  the  angle  of 
internal  deflection  is  reduced  from  twelve  degrees 
in  moderate  cases  to  five  degrees  in  severe  ones. 
From  an  examination  of  severe  cases,  I  have  ascer- 
tained the  average  deviation  from  the  perpendicular 
to  be  about  eight  and  two-tenths  degrees. 

The  prognosis  in  cases  of  flat-foot  depends  in  a 
larsfe  degree  on  the  causes  which  occasion  the  de- 
formity,  the  surroundings  of  the  patient,  and  the 
time  when  he  comes  under  treatment.  In  the  con- 
genital form  of  the  disease,  when  it  is  not  of  great 
severity,  the  prognosis  is  usually  a  favorable  one, 
but  the  severer  cases,  and  those  which  have  been 
allowed  to  go  on  for  a  long  time,  are  usually  more 
resistant,  and  often  necessitate  protracted  treatment. 
In  the  acquired  form,  occurring  as  it  usually  does 
in  the  poorer  classes,  although  the  wealthy  are  by 
no  means  exempt,  and  being  mostly  met  with  in 


FLAT-FOOT.  277 

those  who  are  dependent  for  their  support  on  their 
vocation,  the  prognosis  is  not  so  favorable,  many 
of  these  cases  not  coming  under  treatment  until 
the  pain  becomes  excessive  and  the  deformity  far 
advanced.  Still,  where  the  hygienic  and  other  sur- 
roundings can  be  improved  and  the  patients  placed 
under  favorable  conditions,  and  when  the  disease  is 
not  the  result  of  incurable  paralysis  or  of  chronic 
joint  lesions,  I  know  of  no  disease  in  which  so  much 
can  be  done  for  the  relief  of  pain,  and  in  which  such 
gratifying  results  can  be  accomplished,  although 
much  time  and  patience  may  be  necessary  for  the 
removal  of  the  deformity. 

Concerning  the  treatment  of  flat-foot  very  little 
need  be  said  regarding  the  congenital  type  of  the 
deformity.  When  seen  shortly  after  birth  the 
patients  may  be  successfully  treated  by  manipula- 
tions alone,  these  having  for  their  object  the  carry- 
ing of  the  foot  to  a  more  inverted  position.  To 
retain  the  advantage  gained  by  these  movements 
moleskin  adhesive  plaster  (Maws,  London),  with  a 
roller  bandage,  may  be  employed  to  draw  the  foot 
into  the  varus  position.  When  the  deformity  is 
more  severe,  and  the  child  older,  external  splints  of 
a  simple  character,  composed  of  tin,  gutta  percha, 
or  hatters'  felt,  may  be  employed.  These  are 
moulded  to  the  part,  and  a  gradual  inversion  of 
the  foot  accomplished.  Should  contractions  occur 
which  cannot  be  overcome  by  the  use  of  the 
simple  means  mentioned,  tenotomy  of  the  peronei 
and  extensor  longus  digitorum  becomes  necessary. 
Should  the  tendo  Achillis  be  contracted,  this  will 


278  MEMOIR  OF  A.  S.  ROBERTS. 

also  have  to  be  cut.  These  operations,  however, 
are  best  divided  into  two  stages,  the  peronei  and 
extensor  longus  being  tenotomized  first,  and  the 
tendo  Achillis  subsequently.  Massage  and  elec- 
tricity to  the  weakened  tibial  muscle  may  also  be 
resorted  to  with  the  greatest  advantage.  When 
the  child  is  old  enough  to  walk,  a  simple  support, 
consisting  of  two  lateral  uprights,  connected  with 
a  band  to  encircle  the  calf,  and  with  an  inner  pad 
corresponding  to  the  axis  of  the  astragalo-scaphoid 
articulation,  and  attached  to  the  bottom  of  the 
shoe,  may  be  used. 

The  forms  of  flat-foot  which  we  shall  be  called 
upon  to  treat  frequently  are  those  which  belong  to 
the  acquired  variety.  Here  our  treatment  will,  of 
course,  be  governed  by  the  cause  producing  the 
deformity  and  by  the  amount  of  pain  and  de- 
formity. 

I  have  already,  in  discussing  the  etiology  of 
the  disease,  given  a  brief  account  of  the  different 
causes  operating  to  produce  flat-foot,  and  will  not 
dwell  at  length  on  the  differentiation  of  these 
causes,  but  simply  remark  here  that  any  consti- 
tutional causes  or  diatheses — whether  strumous, 
rhachitic,  or  tubercular — should  receive  careful  at- 
tention. Neither  will  it  come  into  the  province  of 
this  paper  to  discuss  those  extreme  instances  of 
valgus  which,  having  been  neglected  for  years,  pre- 
sent so  much  deformity  that  nothing  but  exsections 
of  the  displaced  tarsus  will  suffice  for  a  restoration 
to  a  useful  foot.  The  symptomatic  valgus  seen  in 
the  course  of  ankle-joint  disease  or  osteitis  of  the 


FLAT-FOOT.  279 

tarsus,  generally  yields  to  the  treatment  employed 
for  the  primary  lesion. 

It  is  on  the  inflammatory  form,  so  called,  that  I 
will  place  especial  stress  in  the  matter  of  treatment. 
I  have  already  alluded  to  the  difficulty  of  obtaining 
rest  for  these  cases,  owing  to  the  fact  that  they  for 
the  most  part  occur  in  the  working  classes,  where 
daily  labor  is  necessary  for  their  support.  Where 
it  can  be  done,  the  removal  of  the  patient  from  all 
employment  suffices,  especially  in  beginning  cases, 
to  pi'omote  a  rapid  cure;  but  even  in  these  cases 
some  support  to  the  weakened  arch  is  called  for. 
This  has  been  accomplished  in  several  ways — 
by  inserting  pieces  of  leather,  pads  of  different 
material  and  construction,  or  tempered  steel  bars 
and  springs  on  the  plantar  surface  of  the  foot. 

While  relief  can  undoubtedly  be  afforded  by  these 
means,  there  are  objections  to  their  use,  chief  among 
these  being  the  expense  of  especially  constructed 
shoes  and  the  introduction  of  these  various  contriv- 
ances. Of  all  those  mentioned,  however,  I  have 
had  the  best  results  from  the  use  of  tempered 
springs  so  made  that  the  convexity  of  the  spring 
shall  be  at  that  point  where  the  arch  of  the  foot  is 
most  flattened.  These  I  have  had  made  to  extend 
from  the  middle  of  the  os  calcis  to  the  base  of  the 
metatarso-phalangeal  articulation,  and  their  object 
is  to  supply  an  artificial  arch  for  the  foot.  They 
have,  however,  to  be  inserted  as  a  shank  into  the 
shoe,  and  this  necessitates  the  construction  of  a 
special  boot  and  oftentimes  the  making  of  a  special 
last  for  the  patient.     Again,  being  very  narrow, 


280 


MEMOIR  OF  A.  S.  ROBERTS. 


they  do  not,  when  there  is  extreme  flattening,  give 
the  desired  amount  of  support,  patients  often  feel- 
ing the  necessity  for  more  pressure  than  can  be 
given  by  them.  I  am  indebted  to  Mr.  Arthur  H. 
Lea,  of  Philadelphia,  for  an  improvement  on  this 
spring,  and  it  gives,  undoubtedly,  the  best  support 
of  all  the  contrivances  I  have  used  or  am  acquainted 
with. 

Fig.  72. 


Upper  surface  of  spring. 
Fig.  73. 


Under  surface  of  spring. 

The  artificial  arch  illustrated  in  the  cut  is  made 
of  tempered  steel.  An  outline  of  the  patient's  foot 
is  first  taken  on  stencil -board,  the  tracing  being 
extended  upward  on  the  inner  side  of  the  foot.  The 
elevated  portion,  corresponding  to  the  depressed 
arch  of  the  foot,  can  be  tempered  to  the  extent 
required  by  the  particular  case.  The  lateral  press- 
ure brought  to  bear  by  the  elevated  flanges  is  such 


FLAT-FOOT.  281 

that,  while  giving  support  to  the  arch  to  a  certain 
extent,  the  artificial  arch  also  prevents  further  dis- 
placement of  the  astragalus  and  scaphoid.  Again, 
in  place  of  giving  only  a  limited  amount  of  support 
to  the  inner  side  of  the  foot,  this  appliance  supports 
the  foot  as  a  whole.  The  objection  urged  against 
the  narrow  spring  is  entirely  avoided  by  the  use  of 
this  one.  It  can  be  placed  in  any  shoe  and  changed 
at  pleasure.  In  most  of  the  cases  in  which  I  have 
used  it  the  spring  is  simply  inserted  into  the  shoe 
without  any  fastening  whatsoever.  The  transition 
from  absolute  disability  to  comparative  freedom 
from  pain  which  the  use  of  this  simple  contrivance 
affords  is  surprising,  and  it  is  all  the  more  grati- 
fying from  its  simplicity  and  easy  adaptability. 
Where  the  disease  has  lasted  for  a  long  time  I 
sometimes  combine  with  it  the  ankle  support  men- 
tioned, and  it  often  serves  as  a  valuable  adjuvant 
in  cases  in  which  the  muscles  and  ligaments  are 
fatigued  from  long  use  in  the  deformed  position. 

I  cannot  close  these  remarks  without  enjoining 
the  necessity  of  proper  massage  and  electricity  to 
the  weakened  parts.  Much  good,  also,  may  be  done 
at  times  by  the  use  of  rubber  bands,  especially  in 
those  cases  in  which  the  tibialis  anticus  is  in  a 
paretic  condition.  Concerning  the  use  of  plaster 
of  Paris  for  the  redressement  of  the  foot,  I  would 
simply  say,  that  the  chief  objection  against  its  use 
lies  in  the  fact  of  its  compelling  the  patient  to  keep 
his  bed,  and  so  depriving  him  of  the  benefit  of  fresh 
air  and  sunlight — both  good  adjuvants  to  the  other 
treatment  recommended. 


CHRONIC   ARTICULAR    OSTEITIS 
OF   THE    KNEE-JOINT: 


WITH    A    DESCRIPTION   OF 


A   NEW    MECHANICAL   SPLINT 


CHRONIC  ARTICULAR   OSTEITIS   OF 
THE  KNEE-JOINT. 


I  have  chosen  the  term  chronic  articular  osteitis 
as  the  one  best  expressing  the  pathological  condition 
found  in  those  lesions  of  the  epiphyses  of  the  knee- 
joint  that  have  usually  been  described  by  the  older 
writers  under  the  caption  "tumor  albus."  My 
reason  for  so  doing  has  been  by  proper  classification 
to  refer  directly  to  inflammation  of  the  cancellous 
structure  of  bone,  thereby  avoiding  the  confusion 
that  usually  exists  if  the  more  general  terms  arthritis 
and  knee-joint  disease  be  employed. 

Before  considering  the  main  feature  of  the  paper, 
viz.,  to  bring  before  your  notice  a  new  mechanical 
splint,  designed  for  the  treatment  of  chronic  articular 
osteitis  of  the  knee-joint,  it  may  be  profitable  to 
review  hastily  the  etiology  and  pathology  of  the 
affection,  the  latter  especially  in  reference  to  its 
clinical  expression,  a  thorough  appreciation  of  which 
aids  so  materially  in  deciding  upon  an  intelligent 
method  of  treatment. 

From  an  analysis  of  many  hundred  cases  of 
articular  osteitis,  I  feel  safe  in  asserting  that  two 
structures  only  are  responsible  for  the  development 
of  chronic  osteitis. 

1.  The  cancellous  structure  of  the  epiphyses. 


286  MEMOIR  OF  A.  S.  ROBERTS. 

2.  The  synovial  membrane. 

Frequently  the  two  are  combined,  and  disease  of 
either  may  develop  from  the  other ;  it  is  not,  how- 
ever, until  the  cartilages  and  ligaments  have  been 
invaded  by  the  inflammatory  process  that  we  are 
justified  in  using  the  term  arthritis. 

The  pathological  changes  that  give  rise  to  the 
more  familiar  clinical  symptoms  may  be  classified 
in  the  following  order: 

A  simple  non-suppurative  osteitis  interna,  the 
primary  lesion  in  the  more  formidable  osteitis  in- 
terna fungiosa,  caseosa,  or  necrotica,  accompanying 
which  suppuration  or  the  formation  of  inflamma- 
tory neoplasia  frequently  adds  serious  complications 
to  the  process  of  cicatrization. 

Of  these  and  the  many  other  subdivisions  of 
chronic  articular  lesions  designated  by  different 
pathologists,  only  two  demand  special  consideration 
— the  fungoid  and  suppurative,  to  which  we  may 
add  the  non-humid  variety  of  old  age,  the  "  caries 
sicca  "  of  Billroth. 

In  all  save  the  necrotic  variety  the  process  of 
destruction  is  by  molecular  death  and  absorption, 
or  suppuration  ;  the  character  of  the  discharge  fre- 
quently marking  the  atonic  form  of  the  lesion. 

The  fungous  proliferations  of  a  chronic  synovitis 
may,  from  pressure,  eat  their  way  through  the  car- 
tilage and  produce  by  contiguity  an  osteitis  super- 
ficialis;  traumatism,  by  direct  injury  to  the  articular 
surfaces,  may  produce  the  same  inflammatory  pro- 
cess; seldom,  however,  without  a  predisposition  to 
the  strumous,  tuberculous,  or  rheumatic  diathesis. 


CHRONIC  ARTICULAR  OSTEITIS  OF  KNEE  JOINT.     287 

Any  of  these  inflammatory  conditions  when  exist- 
ing in  the  epiphyses  may  give  rise  to  certain  neural 
disturbances  that  aid  materially  in  their  recognition. 
I  refer  to  the  ever-present  symptom  of  rigidity  of 
the  joint  due  to  a  reflex  spasm  of  the  muscles  that 
control  it.  This  interference  with  normal  joint- 
motion  is  due  to  an  inflammatory  irritation  of  the 
nerves  distributed  through  the  epiphyses,  reflected 
by  their  centripetal  fibres  to  the  multipolar  cells, 
thence  to  the  great  nerve-centres,  causing  the  appre- 
hensive condition  of  pain  and  the  reflex  spasm  and 
consequent  atrophy  of  the  muscles  controlling  the 
articulation.  It  is  to  this  involuntary  muscular 
spasm  that  we  are  indebted  alike  for  a  means  of 
differentiating  true  osteitis  from  many  of  the  dis- 
eases that  simulate  it,  as  well  as  the  insidiously 
progressive  character  of  the  deformity,  i.  e.9  flexion 
of  the  limb  and  the  frequent  subluxation  of  the  head 
of  the  tibia  into  the  popliteal  space.  Accept  what 
definition  we  may  of  the  lesions  found  in  post- 
mortem examinations  of  the  joints,  the  progressive 
character  of  the  disease,  the  tendency  it  presents  to 
frequent  exacerbations  after  long  periods  of  rejDOse, 
the  difficulty  in  controlling  deformity  and  of  reliev- 
ing pain,  the  frequent  formation  of  cold  abscesses, 
all  class  their  treatment  among  the  most  difficult 
problems  that  may  fall  to  the  lot  of  a  general  sur- 
geon. To  meet  the  universally  recognized  prin- 
ciples of  treatment,  i.  e.,  fixation  of  the  joint  and 
extension,  I  have  designed  the  splint  that  I  now 
feel  justified,  from  the  success  that  has  attended  its 
use,  in  presenting  to  the  profession. 


288 


MEMOIR  OF  A.  S.  ROBERTS. 


It  consists  of  two  light  padded  steel  troughs 
(a,  a)  that  are  firmly  secured  to  the  limb  by  encir- 
cling bands  of  surgical  webbing,  affording  absolute 
fixation  to  the  joint  when  the  extending  rods  are 
locked  after  adjustment.     Three  ratchet  extension 


Fig.  74. 


bars  arranged  in  the  form  of  a  triangle  are  placed 
posteriorly,  corresponding  to  the  long  axis  of  the 
limb,  placing  within  the  control  of  the  surgeon  a 
power  that  will  overcome  the  flexion  and  the  ten- 
dency to  the  production  of  deformity,  and  at  the 
same  time  produce  extension.     It  will  be  noticed, 


CHRONIC  ARTICULAR  OSTEITIS  OF  KNEE-JOINT.     289 

in  referring  to  Fig.  74,  that  the  extension  rod,  b, 
acts  directly  upon  the  head  of  the  tibia  and  parallel 
with  the  line  of  contraction  of  the  flexor  group  of 
muscles,  obviating  thereby  the  error  in  the  mechan- 
ical arrangement  of  the  popular  Stromeyer's  splint, 
or  in  all  where  the  power  is  applied  low  down  on 
the  tibia  to  overcome  the  flexion.  Reference  to 
Fig.  75  will  illustrate  diagrammatically  the  point  at 
issue,  i.  e.9  how  to  overcome  the  flexion  and  sub- 
luxation without  establishing  a  fulcrum,  f,  at  the 


surface  of  the  diseased  joint,  which  would  be  the 
case  should  we  apply  our  force  at  p,  a  distance  be- 
low the  insertion,  k,  of  the  resisting  flexor  tendons. 
In  the  splint  under  consideration  the  long  exten- 
sion rod,  c,  is  used  only  as  a  compensating  bar, 
adjusting  the  angle  of  the  splint  to  the  angle  of  the 
flexion  of  the  limb.  The  power  for  restoring  the 
head  of  the  tibia  and  overcoming  the  spasmodic 
contraction  of  the  flexor  muscles  is  applied  directly 
in  the  axis  of  their  contraction.  Through  the 
extension  bar,  b  (Fig.  74),  the  head  of  the  bone 

19 


290  MEMOIR  OF  A.  S.  ROBERTS. 

describes  in  its  restoration  the  arc  of  a  circle,  a  b 
(Fig.  75).  The  compensating  bar  in  correcting  the 
angle  or  flexion  carries  the  limb  through  the  arc 
c  d,  having  a  centre  in  the  end  of  the  femur. 
Mechanically  this  arrangement  of  force  corrects  the 
deformity  and  relieves,  by  extension,  the  reflex 
spasm  of  the  flexor  muscles,  without  crowding 
together  the  diseased  joint-surfaces  or  aiding  in 
subluxating  the  head  of  the  tibia,  as  would  be  the 
case  should  the  limb  proper  be  used  as  the  long 
arm  of  our  lever,  with  the  insertion  of  the  hamstring 
tendons,  instead  of  the  normal  centre  of  motion  of 
the  joint,  as  the  centre  of  motion  of  the  splint.  Sup- 
plementing the  direct  extension  upon  the  contracted 
muscles,  another  bar,  d,  has  been  added  to  aid  in 
steadying  the  joint  and  relieving  interarticular 
pressure.  Its  action  upon  the  limb  is  produced 
tli rough  adhesive  plaster  applied  above  and  below 
the  joint,  to  which  surgical  webbing  has  been  at- 
tached. This  is  firmly  secured  to  the  counter- 
extending  band,  f,  and  to  the  extension  rod,  g, 
affording  a  means  of  direct  extension  always  corre- 
sponding to  the  angle  of  flexion.  The  extension 
bars  are  controlled  by  a  key-and-ratchet  movement 
held  in  place  after  adjustment  by  a  small  ring  and 
pin.  I  have  found  that  this  method  of  securing 
fixation  with  extension  by  a  portable  appliance 
enables  the  patient  to  enjoy,  by  means  of  crutches, 
all  the  hygienic  advantages  of  open  air  and  exer- 
cise, facilitating  thereby  a  better  result  than  would 
otherwise  be  obtained. 


DEFORMITY  OF  THE  FOREARM 
AND  HAND: 


WITH   AN 


UNUSUAL   HISTORY    OF   HEREDITARY 
CONGENITAL   DEFICIENCY. 


DEFORMITY  OF  FOREARM  AND  HAND. 


Aaron  MacIntyee,  aged  seventy-three  years, 
six  feet  four  inches  in  height,  a  peddler  by  trade, 
and  a  native  of  New  Hampshire,  was  admitted  to 
the  Philadelphia  Hospital  on  March  7,  1885.  His 
forearm  and  hands  exhibited  the  following  congen- 
ital deformity : 

On  the  right  side  (see  Fig.  76)  the  humerus  is 
normal  except  that  its  inferior  extremity  is  rounded 

Fig.  76. 


so  that  the  condyloid  notch  is  scarcely  perceptible. 
In  the  forearm  the  ulna  is  absent,  the  radius  form- 
ing with  the  outer  condyle  of  the  humerus  an 
articulation  which  admits  of  limited  motion  in  all 
directions,  but  which  does  not  admit  of  either  com- 


294  MEMOIR  OF  A.  S.  ROBERTS. 

plete  extension  or  flexion.  The  carpal  bones  present 
are  those  which  articulate  with  the  radius,  and  the 
first  two  metacarpal  bones.  The  pisiform,  cunei- 
form, and  unciform  bones  are  absent.  Of  the 
metacarpal  bones,  only  the  first  and  second  are 
present.  The  thumb  and  index  finger  are  present 
and  normal,  except  that  the  first  phalangeal  articu- 
lation of  the  latter  is  anchylosed  and  the  finger  is, 
as  a  whole,  slightly  curved  toward  the  thumb.  The 
third,  fourth,  and  fifth  digits  are  wanting. 

Fig.  77. 


On  the  left  side  (see  Fig.  77)  no  deformity  is 
noticed  until  we  reach  the  metacarpal  bones,  except 
that  the  olecranon  process  of  the  ulna  is  markedly 
curved  toward  the  inner  condyle  of  the  humerus. 
Of  the  metacarpal  bones  the  third  is  absent.  The 
first  and  second  each  have  a  thumb,  the  two  thumbs 
being  united  by  connective  tissue  and  skin,  the 
thumb  nails  being  contiguous,  and  each  complete 
in  itself.  The  metaearpo-phalangeal  joints  are  en- 
larged. The  index  finger  is  somewhat  curved  on 
itself.  The  middle  and  ring  fingers  are  absent. 
This  leaves  a  fissure  between  the  index  and  little 
fingers   which  extends   to   the  wrist,  as   shown    in 


DEFORMITY  OF  FOREARM  AND  HAND. 


295 


Fig.  78.    The  patient  has  considerable  power  in  his 
hands,  with  full  use  of  the  parts  present. 


Fig.  78. 


The  following  history  of  similar  deformities  in 
his  family  is  interesting,  and  there  is  no  reason  for 
doubting  the  veracity  of  the  patient's  statement. 
His  grandmother  on  his  mother's  side  had  one  index 
finger  sthT.  Two  uncles  on  his  mother's  side  had 
each  a  stiff  little  finger.  One  sister  had  a  hand 
deformed  like  the  patient's  left  hand.  She  had  a 
perfect  child.  Another  sister's  child  had  a  hand 
deformed  like  his  right  hand.  The  patient  has  been 
married  twice,  and  is  the  father  of  seven  children. 
The  two  by  his  first  wife  were  perfect.  Of  the  five 
children  by  his  second  wife,  two  were  perfect  and 
three  were  deformed  with  malformations  similar  in 
character  to  his  own. 

Although  many  cases  somewhat  similar  to  or 
resembling  the  one  abo^e  described  have  been  re- 
ported,  principally    by  Annandale,1   to  whom   the 

1  The  Malformations,  Diseases,  and  Injuries  of  the  Fingers  and 
Toes.  Thomas  Annandale,  F.R.C.S.,  Jacksonian  Prize  Essay,  1864. 
Philadelphia,  J.  B.  Lippincott  &  Co.,  1866. 


296  MEMOIR  OF  A.  S.  ROBERTS. 

reader  is  referred  for  a  further  study  of  these  affec- 
tions, the  unusual  heredity  observed  in  the  present 
instance  was  deemed  worthy  of  more  than  passing 
notice.  Here  heredity  seems  to  have  assumed 
unusual  prominence,  several  generations  having 
reproduced  at  one  time  or  another  malformations, 
which,  although  not  absolutely  similar,  have  been 
markedly  so  in  the  type  and  locality  of  the  deform- 
ity. In  studying  the  etiology  of  congenital  mal- 
formations we  find  the  subject  surrounded  by  much 
that  is  mysterious  and  confusing,  owing  to  the 
varying  importance  attached  by  authors  to  the 
influence  of  physical  and  psychical  conditions  of 
the  patients  upon  the  child  in  utero.  I  will  not 
attempt  to  deal  here  with  the  very  extensive  ques- 
tion of  predisposition  to  or  inheritance  of  disease  in 
general,  but  only  briefly  consider  malformations, 
and  especially  those  due  to  arrested  development. 

Hereditary  similarities  have  been  observed  alike 
in  the  most  extensive  and  most  minute  forms. 
These  may  vary  from  the  shape  of  a  particular  part 
of  the  body,  or  of  a  special  organ,  such  as  the  nose 
or  ear,  to  the  small  pigment  stain  known  as  a 
"mother's  mark."  Accompanying  these  physical 
marks,  similar  mental  tendencies  and  physical  car- 
riage can  be  observed  for  successive  generations, 
giving  to  races  and  persons  their  marked  indi- 
viduality, in  the  same  way  that  organs  perfectly 
normal,  but  characteristic,  are  reproduced  and  phys- 
ical defects  and  abnormalities  are  transmitted  from 
parent  to  child.  Most  congenital  malformations, 
especially  those  due  to  arrested  development,  have 


DEFORMITY  OF  FOREARM  AND  HAND.  297 

been  referred  to  pathological  changes  affecting  the 
child  in  utero.  It  being  granted  that  the  foetus  has 
its  own  circulation  and  nutrition,  and  that,  conse- 
quently, disease  of  a  part  may  take  place,  resulting 
in  effusions,  exudations,  atrophies,  and  hypertro- 
phies, with  consequent  marked  nutritive  changes, 
this  will  not  account  for  all  the  malformations  met 
with.  For  whilst  these  lesions  undoubtedly  cause 
certain  deformities,  it  has  been  found  experiment- 
ally, according  to  Wagner,1  that  malformations  may 
be  produced  by  wounding  the  ovum,  and  thus  pre- 
venting the  development  of  the  part  implicated. 

Thus  the  action  of  mechanical  agencies,  such  as 
blows  and  falls  at  an  early  period  of  gestation,  have 
a  claim  as  causative  agents  in  the  production  of 
anomalous  development.  The  question  of  maternal 
impressions,  through  the  influence  of  fright,  shock, 
etc.,  is  also  to  be  considered,  and  their  possibility 
as  factors  cannot  be  entirely  denied  on  a  "priori 
grounds,  the  literature  of  the  subject  abounding  in 
many  instances  where  the  relation  of  cause  and 
effect  is  seemingly  very  clear.  The  result  of  the 
most  recent  investigations,  however,  would  tend  to 
show  that  the  effects  apparently  brought  about  by 
these  are  the  results  of  foetal  disease  or  spontaneous 
amputations.  Simpson2  and  Montgomery3  have 
described  cases  where  portions  of  the  digits  and 
extremities  have  been  so  amputated,  and  Simpson 

1  Manual  of  General  Pathology.     Translation  by  Seguin  and  Van 
Duyn.     New  York,  1876. 

2  Simpson's  Obstetrics,  vol.  ii.  p.  375. 

3  Todd's  Encyclopaedia  of  Anatomy  and  Physiology,  "  Foetus." 

20 


298  MEMOIR  OF  A.  S.  ROBERTS. 

has  called  attention  to  certain  rudimentary  digits 
sprouting  out  from  the  end  of  the  stumps.  These 
effects  have  also  been  demonstrated  by  prepara- 
tions, where  it  is  shown  that  by  the  encircling  of 
the  extremities  by  turns  of  the  umbilical  cord,  or 
by  bands  of  false  membranes,  spontaneous  intra- 
uterine amputations  have  resulted.  Lastly,  slight 
lesions  in  undeveloped  foetal  organs  can  cause  great 
disturbances  by  preventing  proper  nutrition  of  the 
parts,  and  thus,  the  progress,  size,  and  quality  of  the 
organ  being  interfered  with,  the  resulting  adult 
development  is  either  defective  or  entirely  wanting. 
These  in  brief  are  the  causes  of  congenital  mal- 
formations, and,  while  many  of  the  questions  in 
reo-ard  to  this  class  of  cases  are  still  in  doubt,  suffi- 
cient  etiological  explanation  can  be  deduced  in  the 
reasons  already  stated  for  most  of  the  cases  met 
with  without  resorting  to  apparent  coincidences  or 
fanciful  theories. 


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